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cholangitis

ascending cholangitis

introduction

  • 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.

ED Mx of suspected ascending cholangitis

  • 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:
  • 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
  • disposition is usually best to a hospital where there are both ICU and ERCP services available.

DDx

  • 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
cholangitis.txt · Last modified: 2018/12/23 19:58 (external edit)