Ascending cholangitis differential diagnosis: Difference between revisions

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{{Ascending cholangitis}}
{{Ascending cholangitis}}


'''Editor-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [[Mailto:charlesmichaelgibson@gmail.com|[1]]]; '''Associate Editor(s)-in-Chief:'''
'''Editor-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] <nowiki>[[Mailto:charlesmichaelgibson@gmail.com|[1]]]</nowiki>; '''Associate Editor(s'''


== Overview ==
== Overview ==
Line 12: Line 12:


== Differentiating [Disease name] from other Diseases ==
== Differentiating [Disease name] from other Diseases ==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
Ascending cholangitis must be differentiated from other diseases that cause right upper quadrant pain and fever, such as  
 
* [[Acute cholecystitis]]
OR
* [[Acute hepatitis]]
 
* [[Acute pancreatitis]]
[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
* Biliary stricture
 
* Cancer of the [[common bile duct]]
OR
* [[Cholestatic liver disease]]
 
* [[Cirrhosis]]
As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
* [[Duodenal ulcer]]
 
* Gastic ulcer
=== Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3] ===
* [[Pancreatic cancer]]
On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].


=== Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice ===
{| class="wikitable"
{| class="wikitable"
|-
|-
! rowspan="4" |Diseases
! colspan="3" rowspan="3" |Classification of pain in the abdomen based on etiology
| colspan="6" rowspan="1" |'''Clinical manifestations'''
! rowspan="3" |Disease
! colspan="7" rowspan="2" |Para-clinical findings
! colspan="13" rowspan="1" |'''Clinical manifestations'''
| colspan="1" rowspan="4" |'''Gold standard'''
! colspan="2" rowspan="2" |Diagnosis
! rowspan="4" |Additional findings
! rowspan="3" |Comments
|-
| colspan="3" rowspan="2" |'''Symptoms'''
! colspan="3" rowspan="2" |Physical examination
|-
|-
! colspan="3" |Lab Findings
! colspan="9" rowspan="1" |'''Symptoms'''
! colspan="3" |Imaging
! colspan="4" rowspan="1" |Signs
! rowspan="2" |Histopathology
|-
|-
!Symptom 1
!Abdominal Pain
! colspan="1" rowspan="1" |Symptom 2
! colspan="1" rowspan="1" |Fever
!Symptom 3
!Rigors and chills
!Physical exam 1
!Nausea or vomiting
! colspan="1" rowspan="1" |Physical exam 2
!Jaundice
!Physical exam 3
!Constipation
!Lab 1
!Diarrhea
!Lab 2
!Weight loss
!Lab 3
!GI bleeding
!Imaging 1
!Hypo-
!Imaging 2
tension
!Imaging 3
! colspan="1" rowspan="1" |Guarding
!Rebound Tenderness
!Bowel sounds
! colspan="1" rowspan="1" |Lab Findings
!Imaging
|-
|-
|Differential Diagnosis 1
! rowspan="16" |Abdominal causes
|
! rowspan="15" |Inflammatory causes
|
! rowspan="6" |Pancreato-biliary disorders
| colspan="1" rowspan="1" |Acute suppurative cholangitis
|[[RUQ]]
| +
| +
| +
| +
|−
|−
|−
|−
| +
| +
| +
|N
|
|
* Abnormal [[LFT]]
* WBC >10,000
|
|
* Ultrasound shows [[biliary]]<nowiki/>dilatation/stents/tumor
|
|
* Septic shock occurs with features of [[SIRS]]
|-
| colspan="1" rowspan="1" |[[Cholangitis|Acute cholangitis]]
|[[RUQ]]
| +
|−
|−
| +
|−
|−
|−
|−
|−
|−
|−
|N
|
|
* Abnormal [[LFT]]
|
|
* Ultrasound shows [[biliary]]<nowiki/>dilatation/stents/tumor
|
|
* Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
|-
| colspan="1" rowspan="1" |[[Acute cholecystitis]]
|[[RUQ]]
| +
|−
| +
| +
|−
|−
|−
|−
|−
|−
|−
|Hypoactive
|
|
* [[Hyperbilirubinemia]]
* [[Leukocytosis]]
|Ultrasound shows:
* Gallstone
* Inflammation
|
|
* [[Murphy's sign|Murphy’s sign]]
|-
| colspan="1" rowspan="1" |[[Acute pancreatitis]]
|[[Epigastric]]
| +
|−
| +
|±
|−
|−
| +
|−
|±
|−
|−
|N
|
|
* Increased [[amylase]] / [[lipase]]
|
|
* Ultrasound shows evidence of [[inflammation]]
* CT scan shows severity of pancreatitis
|
|
* Pain radiation to back
|-
| colspan="1" rowspan="1" |[[Primary sclerosing cholangitis]]
|[[RUQ]]
| +
|−
|−
| +
|−
|−
|−
|−
|−
|−
|−
|N
|
|
* Increased liver enzymes
* Increased [[IgM]], [[IgG]]4
* [[Anti-neutrophil cytoplasmic antibody]] ([[p-ANCA]])
* [[Anti-nuclear antibody]] ([[ANA]])
* [[Anti-smooth muscle antibody]] (Anti-Sm)
* Anti-endothelial antibody
* Anti-cardiolipin antibody
|ERCP and MRCP shows
* Multiple segmental [[strictures]]
* Mural irregularities
* [[Biliary]] dilatation and diverticula
* Distortion of biliary tree
|
|
* The risk of [[cholangiocarcinoma]] in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
|-
|-
|Differential Diagnosis 2
| colspan="1" rowspan="1" |[[Cholelithiasis]]
|
|[[RUQ]]/[[Epigastric]]
|
|±
|
|−
|
|±
|
|±
|
|−
|
|−
|
|−
|
|−
|
|−
|
|−
|
|−
|Normal to hyperactive for dislodged stone
|
|
* [[Leukocytosis]]
|
|
* Ultrasound shows [[gallstone]]
|
|
* Fatty food intolerance
|-
|-
|Differential Diagnosis 3
!Gastric causes
|
|[[Gastrointestinal perforation]]
|
|Diffuse
|
| +
|
|±
|
| -
|
|±
|
|−
|
|−
|
|−
|
| +
|
| +
|
| +
|±
|Hyperactive/hypoactive
|
|
* WBC> 10,000
|
|
* Air under [[diaphragm]] in upright [[CXR]]
|
|
* [[Hamman's sign]]
|-
|-
!Diseases
! rowspan="3" |Intestinal causes
!Symptom 1
!Disease
! colspan="1" rowspan="1" |Symptom 2
!Abdominal Pain
!Symptom 3
!Fever
!Physical exam 1
!Rigors and chills
! colspan="1" rowspan="1" |Physical exam 2
!Nausea or vomiting
!Physical exam 3
!Jaundice
!Lab 1
!Constipation
!Lab 2
!Diarrhea
!Lab 3
!Weight loss
!Imaging 1
!GI bleeding
!Imaging 2
!Hypo-
!Imaging 3
tension
!Histopathology
!Guarding
|'''Gold standard'''
!Rebound Tenderness
!Additional findings
!Bowel sounds
!Lab Findings
!Imaging
!Comments
|-
|-
|Differential Diagnosis 4
|[[Inflammatory bowel disease]]
|
|Diffuse
|±
|−
|−
|±
|−
| +
| +
| +
|−
|−
|−
|Normal or hyperactive
|
|
* [[Anti-neutrophil cytoplasmic antibody]]([[P-ANCA]]) in [[Ulcerative colitis]]
* [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]]
|
|
* [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]]
|Extra intestinal findings:
* [[Uveitis]]
* [[Arthritis]]
|-
|[[Whipple's disease]]
|Diffuse
|±
|−
|−
|±
|−
| +
| +
|−
|±
|−
|−
|N
|
|
* [[Thrombocytopenia]]
* [[Hypoalbuminemia]]
* [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]]
|[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis.
Images used to find complications
* [[Whipple's disease x ray|Chest and joint x-ray]]
* [[Whipple's disease CT|CT]]
* [[Whipple's disease MRI|MRI]]
* [[Whipple's disease ultrasound|Echocardiography]]
|Extra intestinal findings:
* [[Uveitis]]
* [[Endocarditis]]
* [[Encephalitis]]
* [[Dementia]]
* [[Hepatosplenomegaly]]
* [[Arthritis]]
* [[Ascites]]
|-
! rowspan="4" |Hepatic causes
|[[Hepatitis|Viral hepatitis]]
|[[RUQ]]
| +
|−
| +
| +
|−
|Positive in Hep A and E
| +
|−
|Positive in fulminant hepatitis
|Positive in acute
| +
|N
|
|
* Abnormal LFTs
* Viral serology
|
|
* US
|
|
* Hep A and E have fecal-oral route of transmission
* Hep B and C transmits via blood transfusion and sexual contact.
|-
|[[Liver abscess]]
|RUQ
| +
| +
| +
| +
|−
|±
| +
|−
| +
| +
|±
|Normal or hypoactive
|
|
* CBC
* Blood cultures
* Abnormal [[Liver function test|liver function tests]]
|
|
* US
* CT
|
|
|-
|[[Hepatocellular carcinoma]]/Metastasis
|RUQ
| +
|−
|−
| +
|−
|−
| +
|−
|−
|−
|−
|
|
* Normal
* Hyperactive if obstruction present
|
|
* High levels of [[Alpha-fetoprotein|AFP]] in serum
* Abnormal [[Liver function test|liver function tests]]
|
|
* US
* CT
* Liver biopsy
|Other symptoms:
* [[Splenomegaly]]
* [[Variceal bleeding]]
* [[Ascites]]
* [[Spider nevi]]
* [[Asterixis]]
|-
|[[Budd-Chiari syndrome]]
|[[RUQ]]
|±
|−
|−
|±
|−
|−
|−
|Positive in liver failure leading to varices
|−
|−
|−
|N
|
|
* 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]]<nowiki/>and [[Bilirubin|bilirubin levels]], decreased [[Albumin|serum albumin level]].
|
|
{| class="wikitable"
|Findings on [[CT scan]]<nowiki/>suggestive of Budd-Chiari syndrome include:
* Early enhancement of the [[caudate lobe]] and central liver around the [[Inferior vena cavae|inferior vena cava]]
* Delayed enhancement of the peripheral [[liver]]<nowiki/>with accompanying central low density (flip-flop appearance)
* Peripheral zones of the [[liver]] show reversed [[portal]] [[venous]] [[blood flow]]
* In the [[chronic]] phase, there is [[caudate lobe]]<nowiki/>enlargement and [[atrophy]] of the [[Liver|peripheral liver]] in affected areas
|}
|[[Ascitic tap|Ascitic fluid examination]] shows:
* [[Total protein]] more than 2.5 g per deciliter
* [[White blood cells]] are usually less than 500/μL.
|-
|-
|Differential Diagnosis 5
! rowspan="1" |Peritoneal causes
|
| colspan="1" rowspan="1" |[[Spontaneous bacterial peritonitis]]
|
|Diffuse
|
| +
|
|−
|
|−
|
|Positive in cirrhotic patients
|
|−
|
| +
|
|−
|
|−
|
|±
|
| +
| +
|Hypoactive
|
|
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>
* Culture: Positive for single organism
|
|
* Ultrasound for evaluation of liver cirrhosis
|
|
|-
|-
|Differential Diagnosis 6
! colspan="2" |Hollow Viscous Obstruction
|
|[[Biliary colic]]
|
|RUQ
|
|−
|
|−
|
| +
|
| +
|
|−
|
|−
|
|−
|
|−
|
|−
|
|−
|−
|N
|
|
* ↑ [[bilirubin]] and [[alkaline phosphatase]]
|
|
* Ultrasound
*
|}
|}


Revision as of 13:12, 28 September 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [[Mailto:charlesmichaelgibson@gmail.com|[1]]]; Associate Editor(s

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating [Disease name] from other Diseases

Ascending cholangitis must be differentiated from other diseases that cause right upper quadrant pain and fever, such as

Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + − − − − + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliarydilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + − − + − − − − − − − N
  • Ultrasound shows biliarydilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + − + + − − − − − − − Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + − + ± − − + − ± − − N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Primary sclerosing cholangitis RUQ + − − + − − − − − − − N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± − ± ± − − − − − − − Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastric causes Gastrointestinal perforation Diffuse + ± - ± − − − + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Intestinal causes Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Inflammatory bowel disease Diffuse ± − − ± − + + + − − − Normal or hyperactive Extra intestinal findings:
Whipple's disease Diffuse ± − − ± − + + − ± − − N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Hepatic causes Viral hepatitis RUQ + − + + − Positive in Hep A and E + − Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + − ± + − + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + − − + − − + − − − −
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy
 Other symptoms:
Budd-Chiari syndrome RUQ ± − − ± − − − Positive in liver failure leading to varices − − − N
Findings on CT scansuggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + − − Positive in cirrhotic patients − + − − ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Biliary colic RUQ − − + + − − − − − − − N
  • Ultrasound

References

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