Acute Cholangitis

OVERVIEW:
--Acute cholangitis is a clinical syndrome resulting from stasis and infection in the biliary tract. 
--The most important predisposing factor for acute cholangitis is biliary obstruction and stasis, generally secondary to biliary calculi or a stricture.

CHARCOT'S TRIAD: 
--Fever (90%), RUQ pain (70%), and Jaundice (60%)
--As a whole only 50%-70% of cases possess all three

REYNOLD'S PENTAD:
--Same as above (fever, jaundince, RUQ pain) + AMS (10-20%) and hypotension (~30%)
--occurs in suppurative cholangitis, a more severe form of cholangitis with higher morbidity/mortality.

BACTERIA:
--E. coli, Enterococcus, Klebsiella, Enterobacter, and Anaerobes.

DIAGNOSIS:
--Charcot’s triad
--2/3 of Charcot’s triad + elevated liver enzymes + biliary dilatation based on the Tokyo Guidelines for diagnosis.

IMAGING:
--CBD dilatation is a common finding; RUQ ultrasound is the recommended first imaging test.
--After RUQ u/s, ERCP or MRCP to confirm diagnosis and intervene therapeutically with sphincterotomy, stone extraction, or stent insertion.

ANTIBIOTICS:


Zosyn OR Ancef
Meropenam
Ceftriaxone AND Flagyl
Ciprofloxacin AND Flagyl --80% of patients respond to conservative therapy with antibiotic therapy. Biliary drainage is emergently required in the remaining 20% (ERCP/MRCP).


10-SECOND RECAP:
--Acute cholangitis: biliary tract infection, usually 2/2 obstruction
--Charcot's Triad: fever, jaundice, RUQ pain
--Reynold's Pentad: charcot's + AMS, hypotension
--Diagnosis: hx, labs/LFTs, RUQ u/s, ERCP/MRCP
--Treatment: antibiotics, ERCP/MRCP

Submitted by J. Grover.

Reference(s): Yusoff IF, Barkun JS, et al. "Diagnosis and management of cholecystitis and cholangitis." Gastroenterol Clin N Am 32 (2003) 1145–1168, Uptodate. "Acute Cholangitis," image