J O H N N Y I L I F F

ASCENDING CHOLANGITIS

ANATOMY

CLINICALLY

CLINICALLY

• Charcot's triad consists of fever, RUQ pain, and jaundice (50%-75%- have all three)• Reynolds pentad adds mental status changes

and sepsis to the triad• Fever is present in approximately 90% of cases.• Abdominal pain and jaundice is thought to occur

in 70% and 60% of patients, respectively.• Obs

HISTORY

• Gallstones, CBD stones (28%-70%)• Recent cholecystectomy• Endoscopic manipulation or ERCP, cholangiogram• History of cholangitis• Immunocompromised• Malignancy (10-57%)• Sepsis• Hypotension (30%)- has been reported as the

only symptom in patients on glucocorticoids• Tachycardia

• Biilary obstruction and stasis

THE BUGS

• Escherichia coli (27%-50%)Gram Neg• Klebsiella species (16%-20%)Gram Neg• Enterococcus species (15%)Gram Pos• Streptococcus species (8%)• Enterobacter species (5-10%)• Pseudomonas aeruginosa (7%).

HOW DO THEY GET THERE?

• Disruption of normal barriers• May result in translocation of bacteria from portal

system or duodenum into biliary tree (sphincter of oddi)

• Increase intrabilary pressure increased permeability of bile ductules thus permitting translocation of the bacteria and toxins• Also favours migration of bacteria from bile into

systemic circulation

NORMAL PREVENTATIVE MEASURES

• Continuous bile flushing• Secretory IgA• Kupffer cells

TREATMENT

• ABC• CODE SPESIS• Early Fluids• IV Abx within 1 hour- gold standard as per Surviving Sepsis Guidelines

• Cover for Gram Neg- most important• Start Broad

• amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourlyPLUSgentamicin 4 to 6 mg/kg (child <10 years: 7.5 mg/kg; >10 years: 6 mg/kg) IV, dailyfor up to 3 days (adjust dose for renal function)

• 3rd Gen Ceph if immediate hypersensitivity

ABC

THE BOSS SAYS

• Airway• Breathing• Circulation• Code Sepsis

TREATMENT

• ABC• CODE SPESIS• Early Fluids• IV Abx within 1 hour- gold standard as per Surviving Sepsis Guidelines

• Cover for Gram Neg- most important• Start Broad

• amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourlyPLUSgentamicin 4 to 6 mg/kg (child <10 years: 7.5 mg/kg; >10 years: 6 mg/kg) IV, dailyfor up to 3 days (adjust dose for renal function)

• 3rd Gen Ceph if immediate hypersensitivity

DIFFERENTIALS

• Biliary Leak• Cholecystitis• Pancreatitis• Liver Abscess• Infected Choledochal cyst• Recurrent Pyogenic cholangitis• Mirizzi syndrome• RLL pneumonia• Biliary Tree Malignancy

INVESTIGAITONS

• Bloods- FBC, U+E, COAG, LFTs, ALT, Lipase, CRP, cultures• CXR- ? Perf- unlikely• U/S• CT Abdo- if diagnosis unclear- potential

malignancy• MRCP

DEFINITIVE INPATIENT TREAMENT

• Continue IV ABX 7-10 days• Biliary Drainage- Endoscopic Sphincterotomy +/-

stone retrieval via ERCP

• Adjust Abx depending on response/ cultures• If worsening can consider Tazocin• Discuss with microbiology

• 70-80% respond to IV ABX as conservatively managed patients initially

• ECRP 24-48hours after presentation (90%-95% success) Percutaneous transhepatic cholangiography PTC or open surgical decompression

• If more than 2cm- lithotripsy

• If not improving- urgent surgical decompression severe acute suppurative cholangitis

• Risk factors in those with CBD stone- Smoker, impacted stone, 70+, further GB stones

DEFINITIVE TREATMENT OF CAUSE

• Cholecystectomy• Stent

• Urgent decompression-- Persistent abdo pain- Hypotension despite adequate resus- Fever >39.0*C- Confusion/ delerium

But Doc shes pregnant!!!

PREGANANCY

• Adjust Abs and treat

PROGNOSIS

• Highly variable mortality rates in literature (20%-30% current literature)• Prevent recurrence- stenting/surgery etc

OPINION OF THE SURGEONS

• Ensure quick IVAbs- within 1 hour and ensure Gastro are aware• Keep doing what we are doing!

OPINION OF THE GASTROENTEROLOGISTS

• Quick IVAbs

• http://emedicine.medscape.com/article/774245-overview#a0199• uptodate.com• Lifeinthefastlane.com