Cholangitis resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>}} | {{familytree | | | | | | | | | | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | |!| | |}} | {{familytree | | | | | | | | | | | | | | | | | |!| | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | D01 | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''[[Cholangitis | {{familytree | | | | | | | | | | | | | | | | | D01 | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''[[Cholangitis resident survival guide#Diagnostic Criteria|Diagnostic criteria:]]'''<ref name="Mayumi-2013">{{Cite journal | last1 = Mayumi | first1 = T. | last2 = Someya | first2 = K. | last3 = Ootubo | first3 = H. | last4 = Takama | first4 = T. | last5 = Kido | first5 = T. | last6 = Kamezaki | first6 = F. | last7 = Yoshida | first7 = M. | last8 = Takada | first8 = T. | title = Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. | journal = J UOEH | volume = 35 | issue = 4 | pages = 249-57 | month = Dec | year = 2013 | doi = | PMID = 24334691 }}</ref><br>❑ Systemic inflammation | ||
:❑ Fever >38℃ and/or shaking chills | :❑ Fever >38℃ and/or shaking chills | ||
:❑ WBC | :❑ WBC (×1000/μl) <4, or >10 | ||
:❑ Jaundice | :❑ CRP (mg/dl) ≥1<br> | ||
❑ Cholestasis | |||
:❑ Jaundice with total bilirubin ≥2 (g/dl) | |||
:❑ ALP (IU) >1.5×STD | :❑ ALP (IU) >1.5×STD | ||
:❑ GGT (IU) >1.5×STD | :❑ GGT (IU) >1.5×STD | ||
:❑ AST (IU) >1.5×STD | :❑ AST (IU) >1.5×STD | ||
:❑ ALT (IU) >1.5×STD | :❑ ALT (IU) >1.5×STD<br> | ||
:❑ Evidence of | ❑ Imaging | ||
:❑ Biliary dilatation | |||
:❑ Evidence of etiology (stricture, stone, stent etc.)</div>}} | |||
{{familytree | | | | | | | | | | | | | | | | | |!| | |}} | {{familytree | | | | | | | | | | | | | | | | | |!| | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | E01 | | |E01=<div style="float: left; text-align: left; line-height: 150% "><BR>❑ Hospital admission<BR>❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ Blood C&S<br>❑ Empiric IV antibiotics<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref | {{familytree | | | | | | | | | | | | | | | | | E01 | | |E01=<div style="float: left; text-align: left; line-height: 150% "><BR>❑ Hospital admission<BR>❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ Blood C&S<br>❑ Empiric IV antibiotics<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref> | ||
:❑ Ceftriaxone 1 g IV every 24 hours | :❑ Ceftriaxone 1 g IV every 24 hours + Metronidazole 500 mg IV every 8 hours | ||
'''or''' | '''or''' | ||
:❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours | :❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours<br> | ||
❑ Acute pain management | |||
:❑ Ketorolac 30-60 mg IM/IV single dose | :❑ Ketorolac 30-60 mg IM/IV single dose | ||
'''or''' | '''or''' | ||
:❑ Opioids until drainage or surgical intervention if ketorolac is contraindicated/pain not improving | :❑ Opioids until drainage or surgical intervention if ketorolac is contraindicated/pain not improving<br> | ||
❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]]<ref name="Mayumi-2013">{{Cite journal | last1 = Mayumi | first1 = T. | last2 = Someya | first2 = K. | last3 = Ootubo | first3 = H. | last4 = Takama | first4 = T. | last5 = Kido | first5 = T. | last6 = Kamezaki | first6 = F. | last7 = Yoshida | first7 = M. | last8 = Takada | first8 = T. | title = Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. | journal = J UOEH | volume = 35 | issue = 4 | pages = 249-57 | month = Dec | year = 2013 | doi = | PMID = 24334691 }}</ref></div>}} | |||
{{familytree | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | |}} | {{familytree | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | |}} | ||
{{familytree | | | | | | | | | | | F01 | | | | F02 | | | | F03 | | |F01=Grade 1 (Mild)|F02= Grade 2 (Moderate)|F03= Grade 3 (Severe)}} | {{familytree | | | | | | | | | | | F01 | | | | F02 | | | | F03 | | |F01=Grade 1 (Mild)|F02= Grade 2 (Moderate)|F03= Grade 3 (Severe)}} | ||
{{familytree | | | | | | | | | | | |!| | | | | |!| | | | | |!| | |}} | {{familytree | | | | | | | | | | | |!| | | | | |!| | | | | |!| | |}} | ||
{{familytree | | | | | | | | | | | G01 | | | | G02 | | | | G03 | |G01=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis | {{familytree | | | | | | | | | | | G01 | | | | G02 | | | | G03 | |G01=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]] | ||
:❑ Within 24 hours after diagnosis (every 6-12 hours) | :❑ Within 24 hours after diagnosis (every 6-12 hours) | ||
:❑ During the time zone of 24-48 hours (every 6-12 hours) | :❑ During the time zone of 24-48 hours (every 6-12 hours)</div>|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]] | ||
:❑ Within 24 hours after diagnosis (every 6-12 hours) | :❑ Within 24 hours after diagnosis (every 6-12 hours) | ||
:❑ During the time zone of 24-48 hours (every 6-12 hours) | :❑ During the time zone of 24-48 hours (every 6-12 hours)<br>❑ Immediate biliary tract drainage within 24-48 hours</div>|G03=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]] | ||
:❑ Within 24 hours after diagnosis (every 6-12 hours) | :❑ Within 24 hours after diagnosis (every 6-12 hours) | ||
:❑ During the time zone of 24-48 hours (every 6-12 hours) | :❑ During the time zone of 24-48 hours (every 6-12 hours)<br> | ||
❑ Immediate organ support | |||
:❑ NIPPV/ IPPV | :❑ NIPPV/ IPPV | ||
:❑ Vasopressors | :❑ Vasopressors<br>❑ Urgent biliary tract drainage</div>}} | ||
{{familytree | | | | | | | | | |,|-|^|-|.| | | |!| | | | | |!| |}} | {{familytree | | | | | | | | | |,|-|^|-|.| | | |!| | | | | |!| |}} | ||
{{familytree | | | | | | | | | H01 | | H02 | | |!| | | | | |!| |H01=Improvement|H02=No improvement within the first 24 hours}} | {{familytree | | | | | | | | | H01 | | H02 | | |!| | | | | |!| |H01=Improvement|H02=No improvement within the first 24 hours}} | ||
| Line 87: | Line 93: | ||
| '''Systemic inflammation'''|| ♦ Fever >38℃ and/or shaking chills<br>♦ Evidence of inflammatory response:<br> - WBC (×1000/μl) <4, or >10 <br> - CRP (mg/dl) ≥1 | | '''Systemic inflammation'''|| ♦ Fever >38℃ and/or shaking chills<br>♦ Evidence of inflammatory response:<br> - WBC (×1000/μl) <4, or >10 <br> - CRP (mg/dl) ≥1 | ||
|- | |- | ||
| '''Cholestasis'''|| ♦ Jaundice with total bilirubin ≥2 (g/dl<br>♦ Abnormal liver function tests:<br>- ALP (IU) >1.5×STD <br>- | | '''Cholestasis'''|| ♦ Jaundice with total bilirubin ≥2 (g/dl<br>♦ Abnormal liver function tests:<br>- ALP (IU) >1.5×STD <br>- GGT (IU) >1.5×STD <br>- AST (IU) >1.5×STD <br>- ALT (IU) >1.5×STD | ||
|- | |- | ||
| '''Imaging findings'''|| ♦ Biliary dilatation<br>♦ Evidence of the etiology (stricture, stone, stent etc.) on imaging (abdominal X-ray: KUB, abdominal USG, CT scan, MRI, MRCP and HIDA scan) | | '''Imaging findings'''|| ♦ Biliary dilatation<br>♦ Evidence of the etiology (stricture, stone, stent etc.) on imaging (abdominal X-ray: KUB, abdominal USG, CT scan, MRI, MRCP and HIDA scan) | ||
Revision as of 16:52, 21 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]
Definition
Acute cholangitis is a morbid condition characterized by the acute infection and inflammation of an obstructed bile duct.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Cholangitis can be a life-threatening condition if it becomes suppurative and it must be treated as such irrespective of the causes.[1]
Common Causes
Management
Shown below is a diagram depicting the management of cholangitis according to the Society for Surgery of the Alimentary Tract (SSAT)[3] and Tokyo guidelines for management of cholangitis.[4]
Characterize the symptoms: ❑ RUQ abdominal pain ❑ Intermittent fever &/or chills ❑ Jaundice ❑ Lethargy or confusion | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Altered mental status ❑ Febrile ❑ Dehydrated ❑ Jaundice ❑ Hypotension ❑ Tachycardia ❑ Dyspnea ❑ Hypoxemia ❑ Abdominal tenderness | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Order laboratory tests: ❑ CBC ❑ BMP ❑ CRP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Diagnostic criteria:[4] ❑ Systemic inflammation
❑ Cholestasis
❑ Imaging
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Hospital admission ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ Blood C&S ❑ Empiric IV antibiotics[5]
or
❑ Acute pain management
or
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Grade 1 (Mild) | Grade 2 (Moderate) | Grade 3 (Severe) | |||||||||||||||||||||||||||||||||||||||||||||||||||
❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity
| ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Immediate biliary tract drainage within 24-48 hours | ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Immediate organ support
| |||||||||||||||||||||||||||||||||||||||||||||||||||
| Improvement | No improvement within the first 24 hours | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Finish antibiotic course | Immediate biliary tract drainage within 24 hours | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Treatment for etiology if still needed (endoscopic treatment, percutaneous treatment, or operative intervention) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
†ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic Metabolic Profile; CBC: Complete Blood Count; CBD: Common Bile Duct; CRP: C-reactive protein; ERCP: Endoscopic retrograde cholangiopancreatography; C&S: Culture & Sensitivity; GGT: Gamma-glutamyl transpeptidase; IM: Intramuscular; IPPV: Invasive Positive Pressure Ventilation; IV: Intravenous; IVF: Intravenous fluids; NIPPV: Non Invasive Positive Pressure Ventilation; NPO: Nil Per Oral; RUQ: Right Upper Quadrant; WBC: White Blood Cell; W/: With
Do's
- Perform blood cultures in all patients with suspicion or diagnosis of cholangitis in order to direct the antibiotic therapy.
- Biliary drainage is done with ERCP, which is the gold standard for both diagnosis and treatment of acute cholangitis.[6] It is preferred over both surgical and percutaneous biliary drainage.[7]
- Consider transferring the patient with grade 2 (moderate) and grade 3 (severe) severity to another hospital if immediate (within 24-48 hours) or urgent biliary tract drainage cannot be performed due to the lack of facilities or skilled personnel.
- Obtain cultures from bile or stents removed at ERCP for grade II (moderate) and III (severe) patients.
- Cholecystectomy should be performed for cholecystolithiasis after acute cholangitis has resolved.
- If ERCP drainage is not possible, percutaneous transhepatic biliary drainage or surgical decompression with CBD exploration and stone removal are the alternate options.
- Consider the placement of a T-tube drainage that allows biliary access for stone removal if the patient is unstable and stone removal is not possible.
- For large impacted stones where ERCP, percutaneous methods, and/or operative interventions are not possible, choledochoduodenostomy or choledochojejunostomy may be necessary.
Dont's
Occlusive cholangiography should not be performed in patients with acute cholangitis since it can lead to the development of septicemia.
Diagnostic Criteria
Shown below are the diagnostic criteria for acute cholangitis according to Tokyo guidelines:[4]
- The diagnosis is "suspected" in the case of the presence of one item in systemic inflammation with one item in either cholestasis or imaging findings.
- The diagnosis is "definite" in the case of the presence of one item in systemic inflammation, one item in cholestasis and one item in imaging.
| Clinical Manifestations | Changes from the baseline |
|---|---|
| Systemic inflammation | ♦ Fever >38℃ and/or shaking chills ♦ Evidence of inflammatory response: - WBC (×1000/μl) <4, or >10 - CRP (mg/dl) ≥1 |
| Cholestasis | ♦ Jaundice with total bilirubin ≥2 (g/dl ♦ Abnormal liver function tests: - ALP (IU) >1.5×STD - GGT (IU) >1.5×STD - AST (IU) >1.5×STD - ALT (IU) >1.5×STD |
| Imaging findings | ♦ Biliary dilatation ♦ Evidence of the etiology (stricture, stone, stent etc.) on imaging (abdominal X-ray: KUB, abdominal USG, CT scan, MRI, MRCP and HIDA scan) |
Severity Assessment Criteria
The severity assessment criteria for acute cholangitis according to Tokyo guidelines is as follows.[4]
Grade III Acute Cholangitis
Grade III or severe acute cholangitis is characterized by the onset of dysfunction in at least one of the following:
- Cardiovascular system: decreased blood pressure that necessitate the administration of dopamine (>5 μg/kg/min) or norepinephrine
- Neurological system: abnormal consciousness
- Respiratory system: PaO2/FiO2 ratio <300
- Renal system: serum creatinine >2.0 mg/dl, decreased urine output
- Hepatic system: PT-INR >1.5
- Hematological system: platelet count < 100,000/mm3
Grade II Acute Cholangitis
Grade II or moderate acute cholangitis is characterized by the presence of any two of the following:
- Abnormal WBC count: >12,000/mm3, <4,000/mm3
- Fever ≥39°C
- Age ≥75 years
- Elevated total bilirubin ≥5 mg/dl
- Decreased albumin level <0.7 x STD
Grade I Acute Cholangitis
Grade I or mild acute cholangitis does not meet the criteria of neither grade II (moderate) or grade III (severe) acute cholangitis.
References
- ↑ 1.0 1.1 Kimura, Y.; Takada, T.; Kawarada, Y.; Nimura, Y.; Hirata, K.; Sekimoto, M.; Yoshida, M.; Mayumi, T.; Wada, K. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 15–26. doi:10.1007/s00534-006-1152-y. PMID 17252293.
- ↑ Lipsett, PA.; Pitt, HA. (1990). "Acute cholangitis". Surg Clin North Am. 70 (6): 1297–312. PMID 2247816. Unknown parameter
|month=ignored (help) - ↑ Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease". J Gastrointest Surg. 16 (11): 2011–25. doi:10.1007/s11605-012-2024-1. PMID 22986769. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 4.2 4.3 4.4 Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis". J UOEH. 35 (4): 249–57. PMID 24334691. Unknown parameter
|month=ignored (help) - ↑ Solomkin, JS.; Mazuski, JE.; Baron, EJ.; Sawyer, RG.; Nathens, AB.; DiPiro, JT.; Buchman, T.; Dellinger, EP.; Jernigan, J. (2003). "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections". Clin Infect Dis. 37 (8): 997–1005. doi:10.1086/378702. PMID 14523762. Unknown parameter
|month=ignored (help) - ↑ Agarwal, N.; Sharma, BC.; Sarin, SK. (2006). "Endoscopic management of acute cholangitis in elderly patients". World J Gastroenterol. 12 (40): 6551–5. PMID 17072990. Unknown parameter
|month=ignored (help) - ↑ Lee, JG. (2009). "Diagnosis and management of acute cholangitis". Nat Rev Gastroenterol Hepatol. 6 (9): 533–41. doi:10.1038/nrgastro.2009.126. PMID 19652653. Unknown parameter
|month=ignored (help)