Acute cholangitis

Gallstones. Gallstones. More gallstones.


Acute cholangitis

Definition: inflammation and infection of the bile duct caused by obstruction, usually by gallstones

Aetiology/ risk factors:

Occurs when there is complete obstruction of the common bile duct resulting in cholestasis and infected bile.

Image result for biliary systemGallstones can be pigment stones, cholesterol stones or mixed.

R/F for gallstones: Female, Fat, Forty, Fertile (do not say this to a patient!)

Also-parenteral nutrition, drugs (OCP, octreotide), FHx, interruption of enterohepatic circulation of bile salts (e.g. Crohn’s disease), terminal ileal resection. Pigment stones: haemolytic disorders (e.g. Sickle cell), liver cirrhosis

R/F for stones becoming symptomatic: smoking, parity (previously carried pregnancies to viable gestational age).

Less common causes of acute cholangitis: iatrogenic biliary duct injury (e.g. during cholecystectomy) causing stricture, chronic pancreatitis causing biliary stricture, chemotherapy/ radiation-induced biliary injury, sclerosing cholangitis (1ry or 2ry), parasite entry into bile ducts, malignant strictures etc.

Epidemiology:

-Gallstones very common- prevalence = 8% of those over 40 years. 90% remain asymptomatic.

-Cholangitis is relatively uncommon, presenting as a complication in about 1% of cases of gallstones.

Symptoms:

-Sudden onset, severe right upper quadrant pain

-Fever

-pruritus

Signs:

-RUQ or epigastric tenderness

-jaundice

-rigors (pyrexia)

=Charcot’s triad

+ hypotension and confusion = Reynold’s pentad

Investigations:

-Bloods

FBC- ↑WCC, ↓platelets  CRP

LFTs- ↑bilirubin, ↑alkaline phosphatase, transaminases may be elevated

U&Es- urea and creatinine elevated in severe cases

Blood cultures-evidence of sepsis? (usually gram -ves)

ABG- metabolic acidosis in severe cases (sepsis)

Coagulation- Prothrombin time may be raised with sepsis

Amylase- risk of pancreatitis

Ultrasound– may show gallstones in common bile duct, and dilation of common bile duct, indicative of obstruction. USS is more sensitive to stones in the gallbladder than in the ducts. (Common bile duct dilatation if > 6cm)

ERCP/MRCP (endoscopic retrograde/ magnetic resonance cholangiopancreatography) = ERCP allows for direct observation of bile duct stone or other obstruction and is a good first intervention as it has therapeutic value

Management:

-IV fluid resuscitation

-NBM

-Antibiotics e.g. IV CEFUROXIME (cephalosporin) (1.5g/8h) & IV/PR METRONIDAZOLE (500mg/8h)

-Analgesia (e.g. pethidine or morphine)

-Anti-emetics

Biliary decompression

-within 24 to 48h, but more urgent in severe cases

→ERCP with biliary sphincterotomy (cut the sphincter of Oddi) and stone extraction. If this is not successful- lithotripsy (stone fragmentation), papillary balloon dilation (at the duodenal papilla, where the dilated junction of the bile and pancreatic ducts- ampulla of Vater- enters the duodenum) and long-term biliary stenting.

Image result for papillary ballooning biliary

Image result for papillary ballooning biliary

-If ERCP fails, percutaneous drainage or surgical common bile duct exploration may become necessary.

-This is followed up by a cholecystectomy.

Cholecystectomy

Definition: surgical removal of the gallbladder. Laparoscopic is usually the first choice. Open surgery may be more suitable in some cases e.g. GB perforation, suspected GB cancer, conversion from laparoscopic if there are difficulties.

Indications: acute and chronic cholecystitis, biliary colic, obstructive jaundice with common bile duct stones, cholangitis, gall bladder perforation, gall bladder cancer

Complications: bleeding, infection, bile leak, bile duct injury, post-cholecystectomy syndrome (persistent dyspeptic syndrome), biliary stricture, incisional hernias

Complications:

-Sepsis (toxic cholangitis), hypotension, multi-organ failure

-Post-ERCP Pancreatitis, or pancreatitis caused by the gallstone in the distal common bile duct

-Iatrogenic bile duct injuries

-Post-sphincterectomy bleeding

-hepatic abscess

Prognosis: if adequate biliary drainage is quickly obtained, most patients experience rapid clinical improvement

References: Cheese & Onion, Rapid Surgery, BMJ Best Practice
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