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| {{Infobox_Disease |
| | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {| class="infobox" style="float:right;" |
| Image = Recurrent_pyogenic_cholangitis_MRI_105.jpg|
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| Caption = Recurrent pyogenic cholangitis. <br> ([http://www.radswiki.net Image courtesy of RadsWiki])|
| | | [[File:Siren.gif|link=Cholangitis resident survival guide|41x41px]]|| <br> || <br> |
| DiseasesDB = 2514 |
| | | [[Cholangitis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| ICD10 = {{ICD10|K|83|0|k|80}} |
| | |} |
| ICD9 = {{ICD9|576.1}} |
| | {{Cholangitis}} |
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| MedlinePlus = |
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| eMedicineSubj = med |
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| eMedicineTopic = 2665 |
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| eMedicine_mult = {{eMedicine2|emerg|96}} |
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| MeshID = D002761 |
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| }}
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| {{SI}} | |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} '''Assosciate Editor(s)-In-Chief:''' {{ADS}}, [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]], {{FH}} |
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| {{Editor Help}} | | {{SK}} Cholangitis; bile duct infection; bile duct inflammation; common bile duct inflammation; common bile duct infection |
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| ==Overview== | | ==[[Cholangitis overview|Overview]]== |
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| '''Cholangitis''' is a clinically defined syndrome of [[fever]], [[right upper quadrant pain]] and [[jaundice]] caused by infection of [[bile]] and inflammation of the biliary tree, usually due to obstruction and stasis. Cholangitis was first described as a life-threatening disorder in 1877 by Charcot. In 1955, Reynolds and Dargan recognized that [[septic shock]] and mental status changes portended a poor outcome. (Reynolds’s Pentad). <ref>Kadakia S. Biliary Tract Emergencies. Med Clin North Amer. 1993, 77(5) 1015-1036. PMID 8371614</ref> <ref>Carpenter H. Bacterial and Parasitic Cholangitis. May Clin Proc. 1998, 73:473-478. PMID 9581592</ref> <ref>Leese T, Neoptolemos JP, Baker AR. Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg. 1986, 73:988. PMID 3790964</ref> <ref>Lai ECS, Mok FPT, Tan ESY. Endoscopic biliary drainage for severe acute cholangitis. NEJM 1992, 326:1582-6. PMID 1584258</ref>
| | ==[[Cholangitis historical perspective|Historical Perspective]]== |
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| == Epidemiology and Demographics == | | ==[[Cholangitis classification|Classification]]== |
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| Parasites are commonly associated with cholangitis outside of the United States. Parasites associated with cholangitis include the Ascaris, Opisthorchis, Clonorchis, Fasciola and Echinococcus. Ascaris is thought to be the etiologic agent of recurrent pyogenic cholangitis (Oriental cholangiohepatitis) found in Hong Kong, Southeast Asia, Columbia, Italy and South Africa. As they migrate to the biliary tree, they bring gut flora with them predisposing to bacterial infection. Dying worms lead to [[inflammation]], [[granulomatous]] scarring and [[fibrosis]] which may lead to [[biliary cirrhosis]]. Opisthorchis and Clonorchis are transmitted by raw fish in Asia, Europe and Siberia and “frequently” lead to the development of [[cholangiocarcinoma]]. Fascioloa is transmitted by colonized watercress and does not predispose to cholangiocarcinoma.
| | ==[[Cholangitis pathophysiology|Pathophysiology]]== |
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| == Pathophysiology == | | ==[[Cholangitis causes|Causes]]== |
| | ==[[Cholangitis differential diagnosis|Differentiating Cholangitis from other Diseases]]== |
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| The presence of [[gallstones]] alone predisposes to bacterial colonization. 70% of patients with gallstones will have bacteria in the bile while normal bile is usually sterile. CBD have a higher probability of infection. 80% of stones can be culture positive.
| | ==[[Cholangitis epidemiology and demographics|Epidemiology and Demographics]]== |
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| The source of biliary infection is usually ascending from the [[duodenum]] or [[jejunum]] and less commonly direct hematogenous seeding of the [[Portal venous system|portal system]]. In the presence of obstruction, the small [[bowel]] becomes colonized with colonic flora. The common organisms are [[E.coli]], [[Klebsiella]], [[Enterococcus]], [[Enterobacter]], [[Proteus]]. [[Anaerobic organism|Anaerobes]] ([[Strep]], [[Bacteroides]], [[Clostridia]]) can be found particularly in the elderly. Higher incidence of [[Pseudomonas]] in those who have been instrumented. Broad spectrum antibiotics to cover [[Gram-negative bacteria|Gram negatives]] including [[Pseudomonas]], Enterococcus and anaerobes are needed up front. [[Cephalosporins]] should not be used as [[monotherapy]]. [[Cipro]] has been shown in one study to be as effective as monotherapy despite poor coverage for anaerobes and EC.
| | ==[[Cholangitis risk factors|Risk Factors]]== |
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| The most common causes of biliary obstruction are [[Gallstone|biliary calculi]], benign stricture or malignant [[neoplasms]]. Benign strictures are caused by primary [[Sclerotherapy|sclerosing]] cholangitis, [[ischemic]] cholangitis, [[iatrogenic]] [[biliary tract]] injury, [[congenital disease]] and [[infection]]. Chronic inflammation predisposed to the development of cholangiocarcinoma. Extraluminal obstruction can occur from [[pancreatic cancer]] or [[pseudocyst]], [[lymphoma]], [[hepatoma]], [[metastatic]] disease or ampullary cancer.
| | ==[[Cholangitis screening|Screening]]== |
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| Biliary obstruction leads to elevated biliary pressures, favoring migration of bacteria into the portal circulation and bile. As pressures increase [[hepatocyte]] secretion is impaired and bacteria move into the [[lymphatics]] and [[systemic circulation]].
| | ==[[Cholangitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| == Diagnosis == | | ==Diagnosis== |
| | [[Cholangitis history and symptoms|History and Symptoms]] | [[Cholangitis physical examination|Physical Examination]] | [[Cholangitis laboratory findings|Laboratory findings]] | [[Cholangitis x ray|X Ray]] | [[Cholangitis CT|CT]] | [[Cholangitis MRI|MRI]] | [[Cholangitis ultrasound|Ultrasound]] | [[Cholangitis other imaging findings|Other Imaging Findings]] | [[Cholangitis other diagnostic studies|Other Diagnostic Studies]] |
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| 50-60% of patients will have all three of Charcot’s triad. 95% will have fever, 66% [[abdominal pain]], jaundice is noted in 80% (When [[bilirubin]] >2.5). Nonobstructive stones are more likely to present without pain or fever. Elderly patients may present only with [[hypotension]]. Dark urine is noted and acholia can be seen.
| | ==Treatment== |
| | [[Cholangitis medical therapy|Medical Therapy]] | [[Cholangitis surgery|Surgery]] | [[Cholangitis primary prevention|Primary Prevention]] | [[Cholangitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cholangitis future or investigational therapies|Future or Investigational Therapies]] |
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| The combination of [[hyperbilirubinemia]], elevated [[white blood cell]] (WBC) count with bandemia, [[aspartate aminotransferase]] (AST), [[alanine aminotransferase]] (ALT) and [[alkaline phosphatase]] elevations all suggest the diagnosis. Alkaline phosphatase and bilirubin are significantly higher inpatients with [[malignant]] rather than [[benign]] obstruction. In benign obstruction, the bilirubin rarely exceeds 12. [[Gamma-glutamyltransferase]] (GGT) and 5’-nucleotidase confirm a biliary origin of the alkaline phosphatase. The [[prothrombin]] time is often elevated. AST and ALT may be as high as 1000, especially if microabcesses form.
| | ==Case Studies== |
| | [[Cholangitis case study one|Case #1]] |
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| === [[MRI]] and [[CT]] ===
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| CT has a higher sensitivity (63%) and is better to localize the site of obstruction.
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| ===MRI===
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| ([http://www.radswiki.net Images courtesy of RadsWiki])
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| <gallery>
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| Image:Recurrent_pyogenic_cholangitis_MRI_101.jpg|Recurrent pyogenic cholangitis
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| Image:Recurrent_pyogenic_cholangitis_MRI_102.jpg|Recurrent pyogenic cholangitis
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| </gallery>
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| <gallery>
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| Image:Recurrent_pyogenic_cholangitis_MRI_103.jpg|Recurrent pyogenic cholangitis
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| Image:Recurrent_pyogenic_cholangitis_MRI_104.jpg|Recurrent pyogenic cholangitis
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| </gallery>
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| <gallery>
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| Image:Recurrent_pyogenic_cholangitis_MRI_105.jpg|Recurrent pyogenic cholangitis
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| Image:Recurrent_pyogenic_cholangitis_MRI_106.jpg|Recurrent pyogenic cholangitis
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| </gallery>
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| === Other Imaging Findings ===
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| *[[Ultrasound]]: Diagnostic evaluation should proceed first with ultrasound which has an 55-85% sensitivity. Small stones in the common bile duct may be missed. The CBD may not be enlarged early or if the stones has passed. The ducts may be totally normal in PSC.
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| == Treatment ==
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| 80% of patients with acute cholangitis will respond to conservative therapy and elective drainage. In 15-20%, the cholangitis will progress requiring emergent drainage. Markers for these people are persistent abdominal pain, hypotensive, fever >102, and confusion.
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| Patients should be kept [[Nil per os|NPO]], given [[IVF]], broad spectrum ABX, [[Vitamin K]] and be drained. Choices for drainage are [[ERCP]] with stone removal and [[sphincterotomy]]/[[stent]] placement, surgically drainage or percutaneous drainage. Intra[[hepatic]] stones cannot be removed via ERCP and should be drained [[percutaneously]]. [[Clinical trial#Design|Randomized trial]]s comparing ERCP and [[surgery]] showed [[morbidity]] and [[mortality]] benefit for ERCP (4.7-10% versus 10-50%). A nasobiliary catheter can be placed if ERCP is impossible (<5%) either because of [[coagulopathy]] precluding sphincterotomy, too large a stone (>2cm) etc. Next step should be percutaneous drainage as a bridge to elective surgery since emergent surgery has an up to 40% mortality.
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| == References ==
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| {{Reflist|2}}
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| {{SIB}}
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| {{Gastroenterology}}
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
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| | [[Category:Infectious disease]] |
| | [[Category:Surgery]] |
