Name
CHOLANGITIS, ACUTE
DESCRIPTION
DETAIL
CAUSES : . Biliary tract obstruction from: . Stones . Tumor (pancreatic, CBD, ampulla, metastatic) . Benign strictures (postsurgical, PSC) . Parasites (Ascaris) . Pancreatitis . Blood clots . Reflux of small bowel bacteria * Choledochoenterostomy * Sump syndrome . Other . Cholecystitis . Bacteriemia . Surgical, radiographic, endoscopic manipulation . Biliary stent -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS: β’ Acute cholecystitis - pain and tenderness are invariably present. (May be very difficult to distinguish between cholangitis and acute cholecystitis). β’ Pyogenic liver abscess β’ Hepatitis β’ Acute pancreatitis β’ Perforated duodenal ulcer β’ Pelvic infl ammatory disease with peritonitis β’ Kidney stones β’ Pancreatitisβ’ Increasing WBC with left shift β’ Hyperbilirubinemia - in 90% β’ Alkaline phosphatase - increasing in 90% β’ Positive blood culture - in 50% (gram negative aerobes, and some anaerobes) β’ Need to delineate underlying biliary tract abnormality β’ Cholangiography is definitive test β’ Percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP) IMAGING : Ultrasound will diagnose gallbladder stones and common bile duct size, but will demonstrate common bile duct calculi in less than 15% DIAGNOSTIC PROCEDURES: Cholangiography as described above
TYPENOTES
RISK FACTORS: β’ Cholelithiasis β’ Endoscopic or surgical manipulation β’ Foreign bodies, such as parasites, biliary stentGENERAL MEASURES : Control sepsis, then evaluate with cholangiography and treat underlying biliary tract pathology. Urgent bile duct decompression may be necessary. SURGICAL MEASURES : β’ Patients who do not respond to antibiotics and supportive care require emergency decompression of the biliary duct system. This may be accomplished by surgery, endoscopy, or transhepatic cholangiography. β’ In case of obstruction secondary to stones, endoscopic papillotomy and stone extraction will drain the duct and may be defi nitive treatment of the underlying cause and is shown to reduce mortality DIET: Nothing by mouth until acute phase is terminated DRUG(S) OF CHOICE: . Antibiotic regimen should cover gram negative aerobes, enterococci, and anaerobes. . Ampicillin 1 gm q6h IV (substitute ciprofloxacin or levofloxacin in penicillin allergic patient) + . Aminoglycoside (e.g., tobramycin, amikacin is an alternative but is expensive) + . Metronidazole 500 mg q8h IV ALTERNATIVE DRUGS: β’ Piperacillin-tazobactam (Zosyn) OR β’ Ampicillin-sulbactam (Unasyn) OR β’ Ticarcillin-clavulanate (Timentin) PATIENT MONITORING : Requires careful monitoring of hemodynamic parameters PREVENTION/AVOIDANCE : Cholangiography when indicated at time of cholecystectomy with endoscopic, radiographic, or surgical clearance of retained CBD stones POSSIBLE COMPLICATIONS: β’ Hepatic abscess β’ Sepsis β’ Hepatic dysfunction EXPECTED COURSE/PROGNOSIS: β’ Acute cholangitis - good β’ Acute toxic cholangitis - mortality high
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - MALE, COMPLETE BLOOD COUNT, CHOLANGIOGRAM INTRAVENOUS, MRI, LIVER FUNCTION TEST