Diferencia entre revisiones de «Ascending cholangitis»
(Text replacement - "==Diagnosis==" to "==Evaluation==") |
(Text replacement - "AMS" to "altered mental status") |
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| Línea 15: | Línea 15: | ||
*Charcot's Triad: [[Fever]] + [[jaundice]] + [[RUQ pain]] | *Charcot's Triad: [[Fever]] + [[jaundice]] + [[RUQ pain]] | ||
**Occurs in ~50% | **Occurs in ~50% | ||
*Reynold's Pentad: The triad + [[ | *Reynold's Pentad: The triad + [[altered mental status]] + [[hypotension]] | ||
**Occurs in <5% | **Occurs in <5% | ||
**Hypotension may be the only presenting sign in elderly patients | **Hypotension may be the only presenting sign in elderly patients | ||
Revisión del 13:35 31 jul 2016
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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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
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- 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
- RUQ Ultrasound
- 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
- Emergent ERCP
Disposition
- Admit