Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

🚨 Ascending cholangitis is a life-threatening infection of the biliary tree. Patients typically present with Charcot’s triad (fever, jaundice, RUQ pain). If confusion and hypotension are present → Reynolds’ pentad, indicating septic shock. Prompt recognition and urgent biliary drainage are essential.

📌 About

• Serious bacterial infection with inflammation + obstruction of bile ducts.
• Most commonly due to common bile duct (CBD) stones, but may follow strictures, malignancy, or parasites.

🦠 Aetiology

• Gallstones (most common).
• Biliary strictures (post-surgery, chronic inflammation).
• Malignancy (cholangiocarcinoma, pancreatic cancer).
• Parasites (liver flukes in endemic areas).

🧫 Microbiology

• Gram-negative: E. coli, Klebsiella, Pseudomonas, Enterobacter.
• Gram-positive: Enterococcus, Streptococcus, Staphylococcus.

📊 Clinical Features

• Charcot’s triad: RUQ pain, fever/rigors, jaundice.
• Reynolds’ pentad: Above + confusion + hypotension (suggests sepsis).
• Biliary obstruction: Dark urine, pale stools, pruritus.
• Hypotension, altered mental status → severe sepsis/septic shock.

🔎 Diagnostic Criteria (Tokyo Guidelines)

• Clinical: Fever, RUQ pain, jaundice, biliary history.
• Laboratory: ↑ WCC, CRP, deranged LFTs (esp. ALP, GGT, bilirubin).
• Imaging: Biliary dilatation, obstructive lesion.
• Suspected diagnosis: ≥2 clinical features.
• Definite diagnosis: Charcot’s triad OR 2 clinical + labs + imaging.

🧪 Investigations

• Bloods: FBC (↑ WCC), CRP, U&E, LFTs (↑ ALP, GGT, bilirubin).
• Blood cultures: Identify bacteria (esp. in sepsis).
• USS liver: Detects duct dilatation, CBD stones.
• CT abdomen: For complications e.g. abscess.
• ERCP: Gold standard – diagnosis + treatment (stone removal/stenting).

⚠️ Complications

• Sepsis & septic shock → multi-organ failure.
• Liver abscess, gallbladder empyema.
• Acute kidney injury from sepsis/dehydration.
• Biliary cirrhosis from chronic obstruction.

💊 Management

• 🔹 Resuscitation: ABCs, IV fluids, oxygen.
• 🔹 Antibiotics: Broad-spectrum (e.g. cephalosporin + metronidazole, or amoxicillin + gentamicin).
• 🔹 Definitive therapy = Biliary drainage:
  • ERCP with sphincterotomy/stone extraction/stenting (first line).
  • Percutaneous transhepatic drainage if ERCP not possible.
• Cholecystectomy (laparoscopic, within 6–12 weeks if gallstone-related).
• Oncology referral if malignant stricture (palliative stent often placed).

📚 References

• Cholangitis: Diagnosis, Treatment, and Prognosis