Cholangitis

Question 1

What is ascending cholangitis?

Answer 1

bacterial infection (typically E. Coli) of the biliary tree

Question 2

What is the bacteria which most commonly causes ascending cholangitis?

Answer 2

E. coli

Question 3

What is the most common predisposing factor to ascending cholangitis?

Answer 3

gallstones

Question 4

What is the triad used to remember the cardinal signs of ascending cholangitis?

Answer 4

Chacot’s triad: right upper quadrant (RUQ) pain, fever and jaundice

Question 5

In what proportion of patients with ascending cholangitis does Charcot’s triad occur?

Answer 5

20-50%

Question 6

What is the most common clinical feature of ascending cholangitis?

Answer 6

fever (RUQ pain 70%) (jaundice 60%)

Question 7

What are 2 additional features of ascending cholangitis and what do these form?

Answer 7

1. hypotension
2. confusion

Reynods’ pentad (with jaundice, fever, right upper quadrant pain)

Question 8

What are 3 examples of causes of ascending cholangitis?

Answer 8

1. Biliary calculi - 50%
2. Benign biliary strictures - 20%
3. Malignancy - 10-20%

Question 9

What are 3 causes of benign biliary stricture that can lead to cholangitis?

Answer 9

1. Congenital
2. Post-infectious
3. Inflammatory

Question 10

What are 5 sources of malignancy which can contribute to he development of ascending cholangitis?

Answer 10

1. Gallbladder
2. Bile duct
3. Ampulla
4. Duodenum
5. Pancreas

Question 11

What are 5 investigations to perform in suspected ascending cholangitis?

Answer 11

1. Full panel of bloods - LFTs, inflammatory markers
2. US abdomen
3. CT scan
4. MRCP
5. ERCP (therapeutic)

Question 12

What is US abdomen useful for in ascending cholangitis and what are the limitations?

Answer 12

can detect bile duct dilatation but not very good at picking up stones in the mid-distal area of the biliary duct

Question 13

What are the advantages and limitations of using CT for ascending cholangitis?

Answer 13

good anatomical details of biliary tree and may visualise radiopaque stones, but poor at viewing radiolucent cholesterol stones which are the most common

Question 14

What is the most accurate imaging modality to determine a diagnosis of ascending cholangitis?

Answer 14

MRCP - can view gallstones, strictures and can view almost all causes of biliary tree blockage

Question 15

What will MRCP show in ascending cholangitis?

Answer 15

gallstones/strictures, can view almost all causes of biliary tree blockage

Question 16

Within what time frame should ERCP be performed?

Answer 16

after 24-48h

Question 17

What are 6 aspects of management of ascending cholangitis?

Answer 17

1. Fluid resuscitation
2. Broad-spectrum intravenous antibiotics (local guidelines - likely to be AMG abx for abdo infection, amoxicillin, metronidazole, gentamicin)
3. Endoscopic drainage - early ERCP
4. Correct any coagulopathy (may have sepsis)
5. Percutaneous drainage (percutaneous transhepatic cholangiography PTC) or surgical drainage
6. Consider cholecystectomy if gallstones is cause