ascending cholangitis

see also:

• jaundice (icterus)
• cholelithiasis (gallstones)
• the patient with acute RUQ pain in ED
• see EMedicine.com for more details

• ascending cholangitis is sepsis of the biliary tree other than just the gallbladder, resulting from obstruction of the CBD, usually by a gallstone in the CBD (choledocholithiasis), or from extension of sepsis from cholecystitis, but may also occur in patients with primary sclerosing cholangitis / primary biliary cirrhosis
• it may occur after ERCP due to introduction of bacteria into the biliary tree which remains at least partially obstructed
• it is a life threatening condition which requires emergent Rx
• the advent of ERCP has reduced mortality from ~100% to 5-10%, although advanced age, co-morbidities, delay in decompression increase mortality to up to 40%
• it is usually differentiated clinically from cholecystitis by presence of either jaundice or imaging evidence of gas in the biliary tree or dilated CBD.
• also suspect cholangitis in older patients presenting with sepsis and mental status changes
• it should not be confused with primary sclerosing cholangitis which is a chronic liver disease that is thought to be due to an autoimmune mechanism.
• nor should it be confused with recurrent pyogenic cholangitis, sometimes referred to as Oriental cholangiohepatitis, which is endemic to Southeast Asia.

• nil orally
• iv access
• bloods for FBE, U&E, LFT's, lipase, clotting, blood culture
• iv fluid Rx as needed
• commence fluid balance chart
• notify gastroenterology team (for early ERCP) or surgical team ASAP
• commence iv antibiotics after ID approval:
  • eg. Tazocin (piperacillin + tazobactam) 4.5g q8h or meropenem 500mg q8h (WH 2013 surgical guidelines)
• expedite diagnostic imaging if possible (eg. biliary USS) and relief of obstruction via ERCP or PTC
• correct any coagulopathy with vitamin K
• severe cases may warrant IDC
• analgesia preferably opiates such as parenteral morphine or fentanyl
• DVT prophylaxis
• disposition is usually best to a hospital where there are both ICU and ERCP services available.

• pylephlebitis
  • an infective suppurative thrombosis of the portal vein
  • usually secondary to intrabdominal sepsis such as diverticulitis, appendicitis, pancreatitis or inflammatory bowel disease (IBD)
  • usual pathogens Bacteroides fragilis or E. coli
  • presents as fever, jaundice, abnormal LFTs in patient with recent abdo sepsis
  • CT scan may show:
    • gas in the inferior mesenteric vein up to the splenic vein to the portal vein with surrounding fat stranding
    • linear gas collections within the liver