Diagnosis

Cholangitis

Etiology

Pathophysiology - obstruction of the common bile duct [gcm][vsz]

1. Obstruction of biliary flow

2. Acute inflammation and infection of the biliary duct system

3. Bacteria and endotoxins in the vascular and lymphatic drainage systems

Cause [gcm][vsz]

• Usually gram negative enterobacteriacea (E.coli)

• Gallstone

  • Choledocholithiasis

  • Mirizzi syndrome (gallstone in cystic duct or neck of the gall bladder causing compression on common bile duct or common hepatic duct)

• Pancreatitis

• Pancreatic cancer

• Cholangiocarcinoma

• Primary sclerosing cholangitis

• Stricture

• ERCP

• Biliary stent obstruction

• Lemmel’s syndrome (peri-ampullary diverticulum causing distal biliary obstruction)

• Round worm (Ascaris lumbricoides) or tapeworm (Taenia saginata)

• AIDS cholangiopathy

• Strictured bilioenteric anastomosis

Complication

• Septic shock

Epidemiology

Incidence per 100.000 [qsy][mvt]

Approach

• Blood test: complete blood count, complete metabolic profile, liver function tests, CRP, coagulation profile

• Blood culture

• Urinalysis

• Ultrasound abdomen

• CT abdomen

• MRCP

• ERCP

• PTCA

Diagnostic criteria [vsz]

• Evidence of purulent bile (ERCP, PTC, surgery) + SIRS

• Tokoyo guidelines:

  1. Two of three Charcot criteria (fever, right upper abdominal pain, and jaundice)

  2. Systemic inflammation (leukocytosis and elevated CRP)

  3. Abnormal liver tests

  4. Imaging suggestive of biliary dilatation and evidence of etiology (biliary stones, strictures, and stents).

Treatment

1. Prehospital care of the unstable patient: [gcm]

   • Airway, Breathing, Circulation

   • Monitor: pulse oximetry, cardiac monitor, blood pressure, blood glucose

   • Treatment: oxygen and IV fluid resuscitation

2. Blood culture

3. Intravenous antibiotic --> if response, then elective ERCP within 24-48 hrs

4. Severely ill patients --> immediate biliary decompression: [yqm]

   1. Endoscopic (ERCP + sphincterotomy)

   2. Percutaneous (PTC)

   3. Surgical decompression (traditional treatment)

Differential diagnoses

Acute liver failure, Acute mesenteric ischemia, Acute pancreatitis, Appendicitis, Autoimmune hepatitis, Benign bile duct tumor, Cholangiocarcinoma, Cholecystitis, Choledocholithiasis, Cholelithiasis, Cirrhosis, Diverticulitis, Liver abscess, Perforated ulcer, Primary sclerosing cholangitis, Pyelonephritis, Sepsis, Shock