Ascending cholangitis

Background

• Also known as "ascending cholangitis"
• Requires the presence of biliary obstruction and infected biliary tract

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Anatomy & Pathophysiology

• Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
• These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
• Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

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MRCP image of two stones in the distal common bile duct

Causes

• Choledocholithiasis
• Biliary tract stricture
• Compression by malignant disease

Clinical Features

• Charcot's Triad: Fever + jaundice + RUQ pain
  • Occurs in ~50%
• Reynold's Pentad: The triad + altered mental status + hypotension
  • Occurs in <5%
  • Hypotension may be the only presenting sign in elderly patients

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Evaluation

Work-up

• Labs
  • Leukocytosis with neutrophil predominance
  • Elevated alk phos and conjugated bilirubin
  • Blood cultures
• Imaging
  • RUQ Ultrasound
    • Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
    • May miss small CBD stones and in acute cases CBD may not have had time to dilate
• ERCP
  • Should be obtained to confirm the diagnosis and for possible intervention

Management

• Aggressive volume replacement
• Broad-spectrum parenteral antibiotics covering gram negatives, gram positives, and anerobes
  • Piperacillin/tazobactam OR ampicillin-sulbactam OR (ceftriaxone + metronidazole)
• Emergent ERCP

Disposition

• Admit

See Also

• Gallbladder Disease (Main)