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Acutecholangitis 110927014348 Phpapp01

This document discusses acute cholangitis, which is a bacterial infection associated with obstruction of the biliary tree, usually due to gallstones. It causes ascending bacterial infection above the site of obstruction. Clinical presentation includes fever, abdominal pain, and jaundice. Diagnostic workup involves blood tests, imaging like ultrasound or MRCP to identify the cause of obstruction. Treatment is initially intravenous antibiotics and fluid resuscitation. For severe cases or non-response to medical therapy, biliary decompression is needed, usually via endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage. Surgical intervention may be required if other options fail.

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Rabecca Tobing
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61 views25 pages

Acutecholangitis 110927014348 Phpapp01

This document discusses acute cholangitis, which is a bacterial infection associated with obstruction of the biliary tree, usually due to gallstones. It causes ascending bacterial infection above the site of obstruction. Clinical presentation includes fever, abdominal pain, and jaundice. Diagnostic workup involves blood tests, imaging like ultrasound or MRCP to identify the cause of obstruction. Treatment is initially intravenous antibiotics and fluid resuscitation. For severe cases or non-response to medical therapy, biliary decompression is needed, usually via endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage. Surgical intervention may be required if other options fail.

Uploaded by

Rabecca Tobing
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Acute

Cholangitis

Acute Cholangitis
Bacterial infection superimposed on an
obstruction of the biliary tree most
commonly from a gallstone.
May be associated with neoplasm or
stricture.

Pathophysiology
Ascending bacterial infection association
with partial or complete obstruction of bile
ducts.
Hepatic bile is sterile, bile in the bile ducts
is kept sterile by continuous bile flow and
by the presence of antibacterial substances
in bile such as immunoglobulin.
Mechanical hindrance to bile flow
facilitates bacterial contamination.

Pathophysiology
The combination of both significant
bacterial contamination and biliary obstruct
ion is required for its development.
Gallstones are the most common cause of
obstruction in cholangitis.
Other causes are benign and malignant
strictures, parasites, instrumentation of the
ducts and indwelling stents, and partially o
bstructed biliary-enteric anastomosis.

Pathophysiology
The most common organisms cultured
from bile in patients with cholangitis inclu
de Escherichia coli, Klebsiella pneumonia
e, Streptococcus faecalis, and Bacteroide
s fragilis.

Clinical
Presentation

Cholangitis may present as anything from


a mild, intermittent, and self-limited disea
se to a fulminant, potentially life-threaten
ing septicemia.
The patient with gallstone-induced
cholangitis is typically older and female.

Clinical
Presentation

The most common presentation is fever,


epigastric or right upper quadrant pain, and j
aundice.
Charcot's triad are present in about two
thirds of patients.
Progress rapidly with septicemia and
disorientation, known as Reynolds pentad.
Mild hepatomegaly
Peritonitis (uncommon)

Clinical
Presentation
History of the following increases the risk of

cholangitis:
Gallstones, CBD stones
Recent cholecystectomy
Endoscopic manipulation or ERCP, cholangiogram
History of cholangitis
History of HIV or AIDS: AIDS-related cholangitis is
characterized by extrahepatic biliary edema,
ulceration, and obstruction.

Differential
Diagnosis

Cholecystitis
Diverticular disease
Hepatitis
Mesenteric ischemia
Pancreatitis

Work Up
CBC: Leukocytosis
liver function test : hyperbilirubinemia, elevation
of alkaline phosphatase and transaminitis are co
mmon
PT PTT : Do not expect to be elevated unless
sepsis is associated with disseminated
intravascular coagulation or underlying cirrhosis
exists.
C-reactive protein level and erythrocyte
sedimentation rate are typically elevated.

Work Up
Imaging studies are important to confirm
the presence and cause of biliary
obstruction and to rule out other conditions.
Transabdominal ultrasonography is the
initial imaging study of choice. excellent for
gallstones and cholecystitis.
It is highly sensitive and specific for
examining the gallbladder and assessing
bile duct dilatation.

Investigation
Advantages to sonography include the
ability to be performed rapidly at the
bedside by the ED physician, capacity
to image other structures (eg, aorta,
pancreas, liver), identification of
complications (eg, perforation,
empyema, abscess), and lack of
radiation.

Investigation
Disadvantages to sonography include
operator and patient dependence,
cannot image the cystic duct, and
decreased sensitivity for distal CBD
stones.
A normal sonogram does not rule out
acute cholangitis.

Investigation
The definitive diagnostic test is ERC.
In cases in which ERC is not available, PTC
is indicated.
Both ERC and PTC will show the level and
the reason for the obstruction, allow culture
of the bile, possibly allow the removal of ston
es if present, and
drainage of the bile ducts with
drainage catheters or stents.

Investigation
Endoscopic retrograde
cholangiopancreatography (ERCP) is both
diagnostic and therapeutic and is considered the
criterion standard for imaging the biliary system.
o ERCP has a high success rate (98%) and is
considered safer than surgical and
percutaneous intervention.
o Complications include pancreatitis, bleeding,
and perforation.

Investigation
CT scanning and MRI will show
pancreatic and periampullary masses, if
present, in addition to the ductal
dilatation.
Gallstones are poorly visualized with
traditional CT scan.

Investigation
Magnetic resonance
cholangiopancreatography (MRCP) is a
noninvasive imaging modality that is
increasingly being used in the diagnosis
of biliary stones and other biliary
pathology.

Investigation
MRCP is accurate for detecting
choledocholithiasis, neoplasms, strictures,
and dilations within the biliary system.
Limitations of MRCP include the inability
for invasive diagnostic tests such as bile
sampling, cytologic testing, stone removal,
or stenting.
It has limited sensitivity for small stones
(<6 mm in diameter).

Investigation
HIDA and DISIDA scans are functional
studies of the gallbladder.
Advantages include its ability to assess
function and positive results may appear
before the ducts are enlarged
sonographically.
One disadvantage is that high bilirubin
levels (>4.4) may decrease the sensitivity
of the study.

Treatment
The initial treatment : intravenous antibiotics
and fluid resuscitation.
Patients with mild cholangitis, 80-90%
respond to medical therapy.
Approximately 15% do not respond and
subsequently require immediate surgical or
endoscopic decompression.
In severely ill patients, treatment is immediate
biliary decompression.

Treatment
The selection of procedure should be
based on the level and the nature of the
biliary obstruction.
Patients with choledocholithiasis or
periampullary malignancies are best appro
ached endoscopically, with sphincterotom
y and stone removal, or by placement of a
n endoscopic biliary stent.

Treatment
In patients in whom the obstruction is
more proximal or perihilar, or stricture in
a biliary-enteric anastomosis is the cause
or the endoscopic route has failed, percut
aneous transhepatic drainage is used.

Treatment
Where neither ERC nor PTC is possible,
an emergent operation and decompressio
n of the common bile duct with a T tube
may be necessary and life-saving.
Definitive operative therapy should be
deferred until the cholangitis has been tre
ated and the proper diagnosis established
.

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