Cholangitis

Question 1

What is cholangitis?

Answer 1

-bacterial infection of the biliary tract

Question 2

What is the cause of cholangitis?

Answer 2

• cholecystitis
• cholelithiasis
• choledocholiathis
• iatrogenic manipulation of the biliary tract like stents and ERCP

Question 3

What is Charcot’s triad?

Answer 3

1. RUQ pain
2. jaundice
3. fever

Question 4

What is Reynolds pentad?

Answer 4

1. charcots triad plus hypotension and altered mental state

Question 5

What is the differential diagnosis for RUQ pain?

Answer 5

1. gastroeosophageal reflux
2. early appendicitis
3. acute pancreatitis
4. right sided diverticulitis

Question 6

How do we diagnose cholangitis?

Answer 6

blood test: FBC: leucocytosis, increased CRP, LFT’s raised: increased bilirubin, ALP, AST, ALT
imaging: ERCP, MRCP, CT scan, ultrasound,

Question 7

What is the treatment for cholangitis?

Answer 7

1. Because it is a surgical emergency you need to resuscitate the patient
   - good IV access
   - send bloods for cultures specifically
   - watch urine output by catheterising patient
   - make sure MAP is above 65mmHG
   - do CVP line if patient is unresponsive to fluids
2. intravenous antibiotics(ceftriaxone and metronidazole) for 7-10 days
3. biliary drainage and decompression within 24-48 hours
4. ERCP is the treatment of choice
5. PTC(Percutaneous transhepatic cholangiography) if ERCP failed

Question 8

How could we prevent cholangitis?

Answer 8

-cholestectomy

Question 9

What are the complications of cholangitis?

Answer 9

• septic shock
• death
• electrolyte abnormality(dehydration)

Question 10

What about cholangitis do you need to mention in exams?

Answer 10

-it is a surgical emergency

Question 11

How would we do ERCP in these patients?

Answer 11

1. Decompress by doing a endoscopic sphincterotomy and stenting
2. nasobiliary drain-drain the bile to the nose as an external drain

Question 12

What is Mirizzi’s syndrome?

Answer 12

-a condition where a gallstone is stuck in hartmann’s pouch that causes compression of the hepatic duct and causes obstructive jaundice

Question 13

What is the treatment for mirizzi’s syndrome?

Answer 13

1. grade 1- laparoscopic cholecystectomy

2. grade 2 to 4-open cholecystectomy and biliary tract exploration

Question 14

What is the grading system for Mirizzi’s syndrome?

Answer 14

grade 1-no fistula formation
grade 1A- presence of the cystic duct
grade 1B-obliteration of the cystic duct
grade 2: less than 33% of the diameter of the common bile duct
grade 3: 33-66% of the common bile duct
grade 4: more than 66% of the common bile duct

Question 15

What organisms are associated with cholangitis?

Answer 15

1. gram negative- e.coli, enterococcus, enterobacter, klebsiella