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Acute Gallstone Cholangitis
Aka: Acute Gallstone Cholangitis, Ascending Cholangitis, Cholangitis, Suppurative Cholangitis, Charcot's Triad, Reynold's Pentad, Acute Cholangitis
- See Also
- Gallstone (Cholelithiasis)
- Biliary Colic
- Acute Cholecystitis
- Choledocholithiasis
- Acalculous Cholecystitis
- Epidemiology
- Incidence rare under age 40 years
- However can occur in children with risk factors
- Risk Factors
- Choledocolithiasis
- Biliary atresia or Biliary tract stricture
- Surgical anastomotic stricture
- Extrinsic compression from malignancy
- Liver transplant history
- Roux-en-Y Bypass Surgery
- Pathophysiology
- Reflux of Bacteria into the Lymphatics, hepatitic veins
- Results in systemic spread
- Complete biliary obstruction in presence of Bacteria (Gram Negative Bacteria, Anaerobic Bacteria)
- E. coli (25-50%)
- Klebsiella (15-20%)
- Enterobacter (5-10%)
- Enterococcus (10-20%)
- Bacteroides
- Clostridium
- Pseudomonas
- Symptoms
- See Acute Cholecystitis
- See Biliary Colic
- Nausea or Vomiting
- Signs
- Charcot's Triad (seen in only 25% of patients)
- Fever
- Jaundice
- Right Upper Quadrant Abdominal Pain
- Reynold's Pentad (seen in only 14% of patients)
- Charcot's Triad and
- Hypotension (Shock) and
- Altered Mental Status
- Other findings
- Toxic appearance
- Hepatomegaly (with tender liver edge)
- Splenomegaly
- Labs
- Complete Blood Count
- Leukocytosis
- Liver Function Tests abnormal
- Bilirubin elevated in urine and plasma (40% of cases)
- Serum alkaline phsophatase elevated
- Blood Cultures (positive in 50% of cases)
- Differential Diagnosis
- Acute Cholecystitis
- Post-op status (esp. Laparoscopic Cholecystectomy) Bile Duct Injury with Biliary Leak
- Acute Pancreatitis
- Liver Abscess
- Prognosis
- Mortality 100% if missed or incorrectly treated
- Management
- See Acute Cholecystitis
- See Cholecystectomy
- Broad spectrum parenteral antibiotics
- Initial antibiotic regimen
- Piperacillin-Tazobactam 4.5 g IV q8 hours OR
- Ertapenem 1 g IV every 24 hours OR
- Initial antibiotic regimen for life threatening infection
- Imipenem 0.5 g IV every 6 hours OR
- Meropenem 1 g IV every 8 hours OR
- Doripenem 500 mg IV every 8 hours
- Initial antibiotic regimen for mild to moderate community acquired infection
- Cefazolin
- Cefuroxime
- Ceftriaxone
- Alternative antibiotic regimens
- Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
- Ceftriaxone 2 g IV OR (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
- Risk of Fluoroquinolone resistance
- Additional antibiotics
- Vancomycin
- Added to regimen if Healthcare Associated Infection
- References
- (2019) Acute Cholangitis, Sanford Guide, accessed 3/29/2019
- (2019) Acute Cholangitis, UpToDate, accessed 3/29/2019
- Sepsis management
- See Septic Shock
- Volume Resuscitation
- Vasopressor support as needed
- Rapid decompression of biliary tree
- Endoscopy with ERCP and sphincterotomy
- May be preferred as initial intervention
- Open common bile duct exploration
- High mortality and morbidity
- References
- Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
- Poon (2001) Arch Surg 136:11-6 [PubMed]
- Portincasa (2006) Lancet 368(9531):230-9 [PubMed]