what is cholangitis?
refers to infection of the biliary tract
associated with high morbidity and mortality if untreated
what causes cholangitis?
combo of
- biliary outflow obstruction (bacterial colonisation is unlikely to cause cholangitis)
- biliary infection
during obstruction, stasis of fluid combined with elevated intraluminal pressure allows bacterial colonisation of the biliary tree to become pathological
what causes cholangitis?
any condition which causes occlusion of the biliary tree can
common causes
- gallstones
- ERCP (iatrogenic)
- cholangiocarcinoma
rarer causes
- pancreatitis
- primary sclerosis cholangitis
- ischaemic cholangiopathy
- parasitic infections
what are the most common infective organisms in cholangitis?
- Escherichia Coli
- Klebsiella species
- enterococcus
what are the clinical features of cholangitis?
- RUQ pain
- fever
- jaundice
- pruritis (bile accumulation)
- pale stool and dark urine (obstructive jaundice)
patient may also have a lipid rich diet
what can the PMH of someone with cholangitis include?
- gallstones
- recent biliary tract instrumentation e.g ERCP/cholecystectomy
- previous cholangitis
medications can include
- oral contraceptive
- fibrates
how does a patient with cholangitis appear on examination?
- pyrexia
- rigors
- RUQ tenderness
- confusion
- hypotension
- tachycardia
what is charcots triad?
- Jaundice
- Fever
- RUQ pain
what is Reynolds pentad?
- Jaundice
- Fever
- RUQ pain
- hypotension
- confusion
what two common syndromes are associated with cholangitis?
- charcots triad
- Reynolds pentad
what are the differential diagnosis for cholangitis?
need to identify underlying cause
clinical features are similar to other biliary pathologies
Biliary colic presents with colicky RUQ pain, but no ever, leucocytosis or jaundice
cholecystitis will present with RUQ pain and fever yet jaundice will be absent
what laboratory tests are done in cholangitis?
routine bloods
FBC especially for leucocytosis
LFTs show raised ALP, GGT with raised bilirubin
blood cultures should be taken early before starting broad spectrum antibiotics
what imaging is done in cholangitis?
- US of biliary tract will show bile duct dilation (>6mm) and may show underlying cause e.g gallstones
- goldstandard is ERCP, as its both diagnostic and therapeutic
what is the immediate management for cholangitis?
may present with sepsis so manage quickly
- IV access
- fluid resuscitation
- routine bloods
- blood cultures
- Broad spectrum IV antibiotics
what is the definitive management for cholangitis?
- endoscopic biliary decompression, removing cause of blocked biliary tree
- ERCP with/without sphincterotomy and stunting should clear any obstruction
- too sick to handle ERCP = percutaneous trans hepatic cholangiography is second line.
- may need cholecystectomy long term if gallstones is the root cause
what are the complications of ERCP?
- repeated cholangitis
- pancreatitis
- bleeding (more common in sphincterotomy)
- perforation
