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 = acute bacterial infection of the biliary tree, usually due to obstruction. 💡 Classic presentation: Charcot’s triad (fever + jaundice + RUQ pain). ⚠️ Add confusion + hypotension → Reynolds’ pentad = septic shock, high mortality. 👉 Medical emergency → needs urgent IV antibiotics + biliary drainage (usually ERCP).

📌 About

• Infection + obstruction = rapid progression to sepsis.
• Most often caused by CBD gallstones but may follow strictures, malignancy, or parasites.
• Common in older adults, but can occur at any age if risk factors present.

🦠 Aetiology & Microbiology

• Obstruction: Gallstones (most common), biliary stricture (post-op, PSC), cholangiocarcinoma, pancreatic cancer, parasites (liver flukes in Asia).
• Organisms:
  • Gram -ves: E. coli, Klebsiella, Enterobacter, Pseudomonas.
  • Gram +ves: Enterococcus, Streptococcus, Staphylococcus.

📊 Clinical Features

• Charcot’s triad: RUQ pain + fever/rigors + jaundice.
• Reynolds’ pentad: Above + confusion + hypotension → septic shock.
• Obstructive jaundice features: dark urine, pale stools, pruritus.
• May rapidly deteriorate to multi-organ failure.

🔎 Diagnosis (Tokyo Guidelines)

• Clinical: Fever/rigors, RUQ pain, jaundice, history of gallstones.
• Lab: ↑ WCC, ↑ CRP, deranged LFTs (↑ ALP, GGT, bilirubin).
• Imaging: Dilated bile ducts, obstructing stone/lesion (USS, MRCP, CT).
• Suspected: ≥2 clinical features. Definite: Charcot’s triad OR 2 clinical + labs + imaging.

🧪 Investigations

• Bloods: FBC, U&E, LFTs, CRP, coagulation.
• Blood cultures: important for sepsis management.
• Imaging:
  • USS liver = first line → duct dilatation, gallstones.
  • MRCP for non-invasive imaging.
  • ERCP = gold standard (diagnostic + therapeutic).

⚠️ Complications

• Sepsis ± septic shock → multi-organ failure.
• Liver abscess, gallbladder empyema.
• Acute kidney injury.
• Chronic obstruction → secondary biliary cirrhosis.

💊 Management

1. Resuscitation: ABCs, IV fluids, oxygen, monitoring.
2. Antibiotics: Broad-spectrum → e.g. ceftriaxone + metronidazole OR co-amoxiclav (local policy dependent).
3. Definitive therapy = urgent biliary drainage:
   • ERCP with sphincterotomy + stone extraction/stenting (first line).
   • Percutaneous transhepatic drainage if ERCP not possible.
4. Cholecystectomy: Elective, 6–12 weeks post-resolution if gallstone-related.
5. Oncology referral: If malignant obstruction → palliative stenting ± chemo.

💡 Clinical Pearls

• RUQ pain + rigors + jaundice = 🚨 think cholangitis until proven otherwise.
• Charcot’s triad is present in <20–50% → don’t wait for all 3 features to diagnose.
• Reynolds’ pentad = pre-terminal sepsis → ICU + urgent drainage.
• In OSCE: emphasise “urgent antibiotics + ERCP” for safe marks.

📚 References

• NICE Gallstone & Biliary Disease
• Tokyo Guidelines 2018

Cases — Acute (Ascending) Cholangitis

• Case 1: A 54-year-old man presents with fever, right upper quadrant pain, and jaundice (Charcot’s triad). He is hypotensive and confused on arrival. Bloods show WCC 18, bilirubin 95 µmol/L, ALP and GGT raised. Ultrasound demonstrates a dilated common bile duct with gallstones. Management: Immediate IV fluids, broad-spectrum IV antibiotics (piperacillin–tazobactam), blood cultures taken. Urgent ERCP performed to decompress the biliary system with sphincterotomy and stone removal. Outcome: Rapid improvement in sepsis parameters; discharged after 5 days with elective laparoscopic cholecystectomy arranged to prevent recurrence.
• Case 2: A 72-year-old woman with a history of gallstones presents with 24 hours of abdominal pain, fever, rigors, and jaundice. She develops confusion and hypotension in the ED (Reynolds’ pentad). Labs: raised CRP, bilirubin 120 µmol/L, ALP 550. CT abdomen shows an obstructing CBD stone. Management: Resuscitated with IV fluids, IV meropenem commenced. Transferred to theatre for emergency percutaneous transhepatic biliary drainage (ERCP not immediately available). Outcome: Stabilises post-procedure, with gradual resolution of jaundice. After 2 weeks of recovery, undergoes elective laparoscopic cholecystectomy. Full recovery.

Teaching Commentary 🧑‍⚕️

Acute cholangitis is a surgical emergency caused by biliary obstruction with infection. Classic Charcot’s triad = RUQ pain, fever, jaundice. Reynolds’ pentad adds hypotension and confusion, signalling severe sepsis. The pathophysiology is raised intrabiliary pressure forcing bacteria (often E. coli, Klebsiella, Enterococcus) into the bloodstream. Management priorities: 1) aggressive sepsis resuscitation (IV fluids, antibiotics), 2) source control via biliary decompression (ERCP or percutaneous drainage). Long-term, most patients require cholecystectomy to prevent recurrence. Mortality is high without prompt intervention.