Ascending cholangitis differential diagnosis: Difference between revisions
(5 intermediate revisions by the same user not shown) | |||
Line 2: | Line 2: | ||
{{Ascending cholangitis}} | {{Ascending cholangitis}} | ||
{{CMG}}; {{AE}} {{AHS}} | |||
== Overview == | == Overview == | ||
Ascending cholangitis must be differentiated from other diseases that cause abdominal pain and fever, such as acute cholecystitis, acute hepatitis, acute pancreatitis, biliary leakage or stricture, hepatic abcess, duodenal and gastric ulcer, cholestatic liver disease and pancreatic cancer. During pregnancy, it also needs to be differentiated from HELLP syndrome that also presents with abdominal pain and abnormal liver function tests. | |||
== Differentiating [Disease name] from other Diseases == | == Differentiating [Disease name] from other Diseases == | ||
Ascending cholangitis must be differentiated from other diseases that cause | Ascending cholangitis must be differentiated from other diseases that cause abdominal pain and fever, such as<ref name="MiuraTakada2007">{{cite journal|last1=Miura|first1=Fumihiko|last2=Takada|first2=Tadahiro|last3=Kawarada|first3=Yoshifumi|last4=Nimura|first4=Yuji|last5=Wada|first5=Keita|last6=Hirota|first6=Masahiko|last7=Nagino|first7=Masato|last8=Tsuyuguchi|first8=Toshio|last9=Mayumi|first9=Toshihiko|last10=Yoshida|first10=Masahiro|last11=Strasberg|first11=Steven M.|last12=Pitt|first12=Henry A.|last13=Belghiti|first13=Jacques|last14=de Santibanes|first14=Eduardo|last15=Gadacz|first15=Thomas R.|last16=Gouma|first16=Dirk J.|last17=Fan|first17=Sheung-Tat|last18=Chen|first18=Miin-Fu|last19=Padbury|first19=Robert T.|last20=Bornman|first20=Philippus C.|last21=Kim|first21=Sun-Whe|last22=Liau|first22=Kui-Hin|last23=Belli|first23=Giulio|last24=Dervenis|first24=Christos|title=Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines|journal=Journal of Hepato-Biliary-Pancreatic Surgery|volume=14|issue=1|year=2007|pages=27–34|issn=0944-1166|doi=10.1007/s00534-006-1153-x}}</ref> | ||
* [[Acute cholecystitis]] | * [[Acute cholecystitis]] | ||
* [[Acute hepatitis]] | * [[Acute hepatitis]] | ||
Line 25: | Line 21: | ||
=== Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice === | === Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice === | ||
{| | |||
<span style="font-size:85%">'''Abbreviations:''' | |||
'''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]]</span> | |||
<small> | |||
{| align="center" | |||
|- | |- | ||
! colspan="3" rowspan="3" |Classification of pain in the abdomen based on etiology | | | ||
! rowspan="3" |Disease | {| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | ||
! colspan="3" rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Classification of pain in the abdomen based on etiology | |||
! colspan="2" rowspan="2" |Diagnosis | ! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ||
! rowspan="3" |Comments | | colspan="13" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestations''' | ||
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis | |||
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | |||
|- | |- | ||
| colspan="9" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms''' | |||
! colspan="4" rowspan="1" |Signs | ! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs | ||
|- | |- | ||
!Abdominal Pain | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
! colspan="1" rowspan="1" |Fever | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever | ||
!Rigors and chills | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills | ||
!Nausea or vomiting | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
!Jaundice | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
!Constipation | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | ||
!Diarrhea | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | ||
!Weight loss | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss | ||
!GI bleeding | ! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding | ||
!Hypo- | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | ||
tension | tension | ||
! colspan="1" rowspan="1" |Guarding | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding | ||
!Rebound Tenderness | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | ||
!Bowel sounds | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | ||
! colspan="1" rowspan="1" |Lab Findings | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings | ||
!Imaging | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | ||
|- | |- | ||
! rowspan="16" |Abdominal causes | ! rowspan="16" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal causes | ||
! rowspan="15" |Inflammatory causes | ! rowspan="15" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Inflammatory causes | ||
! rowspan="6" |Pancreato-biliary disorders | ! rowspan="6" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pancreato-biliary disorders | ||
| colspan="1" rowspan="1" |Acute suppurative cholangitis | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Acute suppurative cholangitis | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Abnormal [[LFT]] | *Abnormal [[LFT]] | ||
* WBC >10,000 | *WBC >10,000 | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound shows [[biliary]] | * Ultrasound shows [[biliary]] dilatation/stents/tumor | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Septic shock occurs with features of [[SIRS]] | * Septic shock occurs with features of [[SIRS]] | ||
|- | |- | ||
| colspan="1" rowspan="1" |[[Cholangitis|Acute cholangitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Cholangitis|Acute cholangitis]] | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Abnormal [[LFT]] | * Abnormal [[LFT]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound shows [[biliary]] | * Ultrasound shows [[biliary]] dilatation/stents/tumor | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics | * Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics | ||
|- | |- | ||
| colspan="1" rowspan="1" |[[Acute cholecystitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute cholecystitis|Acute cholecystitis]] | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Hypoactive | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Hyperbilirubinemia]] | * [[Hyperbilirubinemia]] | ||
* [[Leukocytosis]] | * [[Leukocytosis]] | ||
|Ultrasound shows: | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows: | ||
* Gallstone | * Gallstone | ||
* Inflammation | * Inflammation | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Murphy's sign|Murphy’s sign]] | * [[Murphy's sign|Murphy’s sign]] | ||
|- | |- | ||
| colspan="1" rowspan="1" |[[Acute pancreatitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute pancreatitis]] | ||
|[[Epigastric]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[Epigastric]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Increased [[amylase]] / [[lipase]] | * Increased [[amylase]] / [[lipase]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound shows evidence of [[inflammation]] | * Ultrasound shows evidence of [[inflammation]] | ||
* CT scan shows severity of pancreatitis | * CT scan shows severity of pancreatitis | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Pain radiation to back | * Pain radiation to back | ||
|- | |- | ||
| colspan="1" rowspan="1" |[[Primary sclerosing cholangitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary sclerosing cholangitis]] | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Increased liver enzymes | * Increased liver enzymes | ||
* Increased [[IgM]], [[IgG]]4 | * Increased [[IgM]], [[IgG]]4 | ||
* [[Anti-neutrophil cytoplasmic antibody]] ([[p-ANCA]]) | * [[Anti-neutrophil cytoplasmic antibody]] ([[p-ANCA]]) | ||
* [[Anti-nuclear antibody]] ([[ANA]]) | * [[Anti-nuclear antibody]] ([[ANA]]) | ||
* [[Anti-smooth muscle antibody]] (Anti-Sm) | * [[Anti-smooth muscle antibody]] (Anti-Sm) | ||
* Anti-endothelial antibody | * Anti-endothelial antibody | ||
* Anti-cardiolipin antibody | * Anti-cardiolipin antibody | ||
|ERCP and MRCP shows | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |ERCP and MRCP shows | ||
* Multiple | * Multiple segmental [[strictures]] | ||
* Mural irregularities | * Mural irregularities | ||
* [[Biliary]] | * [[Biliary]] dilatation and diverticula | ||
* Distortion of biliary tree | * Distortion of biliary tree | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* The risk | * The risk of [[cholangiocarcinoma]] in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population. | ||
|- | |- | ||
| colspan="1" rowspan="1" |[[Cholelithiasis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cholelithiasis]] | ||
|[[RUQ]]/[[Epigastric]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]/[[Epigastric]] | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Normal to hyperactive for dislodged stone | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal to hyperactive for dislodged stone | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Leukocytosis]] | * [[Leukocytosis]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound shows [[gallstone]] | * Ultrasound shows [[gallstone]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Fatty food intolerance | * Fatty food intolerance | ||
|- | |- | ||
!Gastric causes | ! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gastric causes | ||
|[[Gastrointestinal perforation]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastrointestinal perforation]] | ||
|Diffuse | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
| - | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki> | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|Hyperactive/hypoactive | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive/hypoactive | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* WBC> 10,000 | * WBC> 10,000 | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Air under [[diaphragm]] in upright [[CXR]] | * Air under [[diaphragm]] in upright [[CXR]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Hamman's sign]] | * [[Hamman's sign]] | ||
|- | |- | ||
! rowspan="3" |Intestinal causes | ! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intestinal causes | ||
!Disease | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ||
!Abdominal Pain | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
!Fever | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Fever | ||
!Rigors and chills | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills | ||
!Nausea or vomiting | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
!Jaundice | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
!Constipation | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | ||
!Diarrhea | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | ||
!Weight loss | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss | ||
!GI bleeding | ! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding | ||
!Hypo- | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | ||
tension | tension | ||
!Guarding | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Guarding | ||
!Rebound Tenderness | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | ||
!Bowel sounds | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | ||
!Lab Findings | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Lab Findings | ||
!Imaging | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | ||
!Comments | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
|- | |- | ||
|[[Inflammatory bowel disease]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Inflammatory bowel disease]] | ||
|Diffuse | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Normal or hyperactive | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal or hyperactive | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Anti-neutrophil cytoplasmic antibody]]([[P-ANCA]]) in [[Ulcerative colitis]] | * [[Anti-neutrophil cytoplasmic antibody]] ([[P-ANCA]]) in [[Ulcerative colitis]] | ||
* [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]] | * [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]] | * [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]] | ||
|Extra intestinal findings: | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
Extra intestinal findings: | |||
* [[Uveitis]] | * [[Uveitis]] | ||
* [[Arthritis]] | * [[Arthritis]] | ||
|- | |- | ||
|[[Whipple's disease]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Whipple's disease]] | ||
|Diffuse | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[Thrombocytopenia]] | * [[Thrombocytopenia]] | ||
* [[Hypoalbuminemia]] | * [[Hypoalbuminemia]] | ||
* [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]] | * [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]] | ||
|[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis. | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis. | ||
Images used to find complications | Images used to find complications | ||
* [[Whipple's disease x ray|Chest and joint x-ray]] | *[[Whipple's disease x ray|Chest and joint x-ray]] | ||
* [[Whipple's disease CT|CT]] | *[[Whipple's disease CT|CT]] | ||
* [[Whipple's disease MRI|MRI]] | *[[Whipple's disease MRI|MRI]] | ||
* [[Whipple's disease ultrasound|Echocardiography]] | *[[Whipple's disease ultrasound|Echocardiography]] | ||
|Extra intestinal findings: | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Extra intestinal findings: | ||
* [[Uveitis]] | * [[Uveitis]] | ||
* [[Endocarditis]] | * [[Endocarditis]] | ||
Line 293: | Line 296: | ||
* [[Ascites]] | * [[Ascites]] | ||
|- | |- | ||
! rowspan="4" |Hepatic causes | ! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes | ||
|[[Hepatitis|Viral hepatitis]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]] | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Positive in Hep A and E | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in Hep A and E | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Positive in fulminant hepatitis | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in fulminant hepatitis | ||
|Positive in acute | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in acute | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Abnormal LFTs | * Abnormal LFTs | ||
* Viral serology | * Viral serology | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* US | * US | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Hep A and E have fecal-oral route of transmission | * Hep A and E have fecal-oral route of transmission | ||
* Hep B and C transmits via blood transfusion and sexual contact. | * Hep B and C transmits via blood transfusion and sexual contact. | ||
|- | |- | ||
|[[Liver abscess]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Liver abscess]] | ||
|RUQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|Normal or hypoactive | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal or hypoactive | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* CBC | * CBC | ||
* Blood cultures | * Blood cultures | ||
* | * Abnormal [[Liver function test|liver function tests]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* US | * US | ||
* CT | * CT | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
|- | |- | ||
|[[Hepatocellular carcinoma]]/Metastasis | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatocellular carcinoma]]/Metastasis | ||
|RUQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Normal | * Normal | ||
* Hyperactive if obstruction present | * Hyperactive if obstruction present | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* High levels | * High levels of [[Alpha-fetoprotein|AFP]] in serum | ||
* | * Abnormal [[Liver function test|liver function tests]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* US | * US | ||
* CT | * CT | ||
* Liver biopsy | * Liver biopsy | ||
|Other symptoms: | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
Other symptoms: | |||
* [[Splenomegaly]] | * [[Splenomegaly]] | ||
* [[Variceal bleeding]] | * [[Variceal bleeding]] | ||
Line 370: | Line 374: | ||
* [[Asterixis]] | * [[Asterixis]] | ||
|- | |- | ||
|[[Budd-Chiari syndrome]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Budd-Chiari syndrome|Budd-Chiari syndrome]] | ||
|[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Positive in liver failure leading to varices | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in liver failure leading to varices | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Elevated [[Aspartate aminotransferase|serum aspartate aminotransferase]] and [[alanine aminotransferase]] levels may be more than five times the upper limit of the normal range. | *Elevated [[Aspartate aminotransferase|serum aspartate aminotransferase]] and [[alanine aminotransferase]] levels may be more than five times the upper limit of the normal range. | ||
* Elevated serum [[alkaline phosphatase]] | *Elevated serum [[alkaline phosphatase]] and [[Bilirubin|bilirubin levels]], decreased [[Albumin|serum albumin level]]. | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
{| | {| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | ||
|Findings on [[CT scan]] | |- | ||
* Early enhancement of the [[caudate lobe]] and central liver around the [[Inferior vena cavae|inferior vena cava]] | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Findings on [[CT scan]] suggestive of Budd-Chiari syndrome include: | ||
* Delayed enhancement of the peripheral [[liver]] | *Early enhancement of the [[caudate lobe]] and [[central liver]] around the [[Inferior vena cavae|inferior vena cava]] | ||
* Peripheral zones of the [[liver]] show reversed [[portal]] [[venous]] [[blood flow]] | *Delayed enhancement of the peripheral [[liver]] with accompanying central low density (flip-flop appearance) | ||
* In the [[chronic]] phase, there is [[caudate lobe]] | *Peripheral zones of the [[liver]] show reversed [[portal]] [[venous]] [[blood flow]] | ||
*In the [[chronic]] phase, there is [[caudate lobe]] enlargement and [[atrophy]] of the [[Liver|peripheral liver]] in affected areas | |||
|} | |} | ||
|[[Ascitic tap|Ascitic fluid examination]] shows: | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Ascitic tap|Ascitic fluid examination]] shows: | ||
* [[Total protein]] more than 2.5 g per deciliter | *[[Total protein]] more than 2.5 g per deciliter | ||
* [[White blood cells]] are usually less than 500/μL. | *[[White blood cells]] are usually less than 500/μL. | ||
|- | |- | ||
! rowspan="1" |Peritoneal causes | ! rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Peritoneal causes | ||
| colspan="1" rowspan="1" |[[Spontaneous bacterial peritonitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Spontaneous bacterial peritonitis]] | ||
|Diffuse | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|Positive in cirrhotic patients | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in cirrhotic patients | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|Hypoactive | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small> | * Ascitic fluid [[PMN]]>250 cells/mm<small>³</small> | ||
* Culture: Positive for single organism | * Culture: Positive for single organism | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound for evaluation of liver cirrhosis | * Ultrasound for evaluation of liver cirrhosis | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
|- | |- | ||
! colspan="2" |Hollow Viscous Obstruction | ! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction | ||
|[[Biliary colic]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]] | ||
|RUQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
|N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* ↑ [[bilirubin]] and [[alkaline phosphatase]] | * ↑ [[bilirubin]] and [[alkaline phosphatase]] | ||
| | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Ultrasound | * Ultrasound | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
|- | |||
|} | |} | ||
|} | |||
</small> | |||
==References== | ==References== | ||
Line 447: | Line 456: | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Needs content]] | [[Category: Needs content]] |
Latest revision as of 13:33, 28 September 2018
Ascending cholangitis Microchapters |
Diagnosis |
---|
Treatment |
Case Studies |
Ascending cholangitis differential diagnosis On the Web |
American Roentgen Ray Society Images of Ascending cholangitis differential diagnosis |
Risk calculators and risk factors for Ascending cholangitis differential diagnosis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anila Hussain, MD [2]
Overview
Ascending cholangitis must be differentiated from other diseases that cause abdominal pain and fever, such as acute cholecystitis, acute hepatitis, acute pancreatitis, biliary leakage or stricture, hepatic abcess, duodenal and gastric ulcer, cholestatic liver disease and pancreatic cancer. During pregnancy, it also needs to be differentiated from HELLP syndrome that also presents with abdominal pain and abnormal liver function tests.
Differentiating [Disease name] from other Diseases
Ascending cholangitis must be differentiated from other diseases that cause abdominal pain and fever, such as[1]
- Acute cholecystitis
- Acute hepatitis
- Acute pancreatitis
- Biliary stricture
- Cancer of the common bile duct
- Cholestatic liver disease
- Cirrhosis
- Duodenal ulcer
- Gastic ulcer
- Pancreatic cancer
Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice
Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram
|
References
- ↑ Miura, Fumihiko; Takada, Tadahiro; Kawarada, Yoshifumi; Nimura, Yuji; Wada, Keita; Hirota, Masahiko; Nagino, Masato; Tsuyuguchi, Toshio; Mayumi, Toshihiko; Yoshida, Masahiro; Strasberg, Steven M.; Pitt, Henry A.; Belghiti, Jacques; de Santibanes, Eduardo; Gadacz, Thomas R.; Gouma, Dirk J.; Fan, Sheung-Tat; Chen, Miin-Fu; Padbury, Robert T.; Bornman, Philippus C.; Kim, Sun-Whe; Liau, Kui-Hin; Belli, Giulio; Dervenis, Christos (2007). "Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines". Journal of Hepato-Biliary-Pancreatic Surgery. 14 (1): 27–34. doi:10.1007/s00534-006-1153-x. ISSN 0944-1166.