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.

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