EMed

Ascending cholangitis

Background

  • Biliary obstruction (in the lumen, in the wall or external) plus infection (presumed ascending from duodenum)
  • Patients often confused / septic (>30% develop bacteraemia)
  • Usually E. coli, Klebsiella, Enterococcus. Occasionally strep / pseudomonas
  • M = F, ↑ in elderly, underlying biliary Hx (or recent ERCP)
  • Higher mortality if: ARF, IBD, Shock (septic)

History

Charcot's triad

  • Fever
  • RUQ pain
  • Jaundice

Examination

  • Jaundice
  • Septic
  • Confused
  • Not peritonitic (search for another cause)

Differential Dx

Beware pregnant patient

Pneumonic

  • RLL pathology

Jaundice

  • Liver failure (paracetamol Hx?)
  • Viral hepatitis
  • Cirrhosis / liver abscess

Peritonitic

Investigations

  • Septic / inflam. markers raised
  • Check amylase (and Ca++ if amylase ↑) ±lipase
  • LFT (bilirubin, AP ↑ in cholestasis)
  • INR usually normal (↑ = septic / DIC?)
  • Septic / culture workup
  • US highly sensitive / specific (duct dilatation & gas)
  • CT better if pancreatic aetiology suspected or Dx unclear

Management

  • Check (and address) A,B,C
  • Volume resuscitate (sepsis 6) ±urinary catheter
  • Beware coagulopathy (another eatiology?)
  • Antibiotics (on NCHD.ie)
  • Involve ITU (these generally get a lot worse before improving)
  • In-patient team to arrange ERCP sphincterotomy as appropriate

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 24/10/22.