Acute cholangitis

clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract.

or ascending cholangitis

typically ascend from the duodenum;-sphincter of oddi, IgA and bile mucous
Biliary obstruction raises intrabiliary pressure increases permeability bile ductules
 hematogenous spread from the portal vein is a rare

biliary calculi (28 to 70 percent), benign stenosis (5 to 28 percent), and malignancy (10 to 57 percent)
common complication of stent placement for malignant biliary obstruction (18 percent in one series)

Bile is sterile.

 Bacteriology — Culture of bile, ductal stones, and blocked biliary stents

• Escherichia coli (25 to 50 percent), followed by Klebsiella (15 to 20 percent) and Enterobacter species (5 to 10 percent).
•  +, Enterococcus species (10 to 20 percent).
• Anaerobes, such as Bacteroides and Clostridia, are usually present as part of a mixed infection. 

fever, abdominal pain, and jaundice (Charcot's triad),  50 to 75 percent
 Confusion and hypotension can occur in patients with suppurative cholangitis, producing Reynolds's pentad, which is associated with significant morbidity and mortality

ALT if > 2000 reflects microabscess liver and hepatocyte necrosis.
Raised amylase suggests pancreatitis

 Diagnostic criteria (the Tokyo guidelines) - two or more of the following:

• A history of biliary disease
• Fever and/or chills
• Jaundice
• Abdominal pain

 definite if Charcot's triad (fever, abdominal pain, and jaundice) or
 all present:

• Evidence of an inflammatory response (abnormal white blood cell count, elevated C-reactive protein)
• Abnormal liver tests
• Biliary dilation

 In patients with Charcot's triad and abnormal liver tests, we proceed directly to ERCP to confirm the diagnosis and provide biliary drainage.
If without Charcot's triad, we recommend transabdominal ultrasonography to look for common bile duct dilatation or stones. Then followed  (within 24 hours) by ERCP to provide biliary drainage
 If  ultrasound is normal, we proceed with MRCP to look for bile duct stones or alternative diagnoses
If cannot undergo MRCP, we will proceed with ERCP if the liver tests are suggestive of biliary obstruction
 If the liver tests are normal or if high risk ERCP, we will proceed with EUS to look for evidence of bile duct stones or obstruction.
If this subsequent testing fails to demonstrate biliary obstruction, an evaluation for alternative explanations for the patient's symptoms should be performed

 the diagnosis confirmed by ERCP

The differential diagnosis of fever and abdominal pain includes:

• Biliary leaks-asso with lap cholecystectomy
• Acute diverticulitis 
• Cholecystitis 
• Appendicitis
• Pancreatitis 
• Liver abscess 
• Infected choledochal cysts 
• Recurrent pyogenic cholangitis 
• Mirizzi syndrome 
• Intestinal perforation 
• Right lower lobe pneumonia/empyema
•  
• In general, antibiotics should be continued for 7 to 10 days 

 Biliary drainage — Endoscopic sphincterotomy with stone extraction and/or stent insertion. If fails can proceed with percutaneous transhepatic cholangiography or open surgical decompression
 Biliary drainage can then be performed on an elective basis (within 24 to 48 hours).

 If the patient does not improve over the first 24 hours, urgent biliary decompression is required.
Risk factors include impacted stones, active smoker status, age >70 years, and additional stones within the GB

 signs of acute suppurative cholangitis, such as:

• Persistent abdominal pain
• Hypotension despite adequate resuscitation
• Fever greater than 39ºC (102ºF)
• Mental confusion (a predictor of poor outcome

ERCP — 90 -95% after sphincterotomy. Prior to injection of contrast,  decompress the biliary system to reduce the risk of inducing bacteremia. Occlusive cholangiography should not be performed in patients with acute cholangitis since it can promote the development of septicemia

 Stones more than 2 cm  require lithotripsy. Intrahepatic stones can sometimes be removed with choledochoscopy.
 Endoscopic drainage has lower overall rates of mortality and morbidity compared with surgical decompression ( 4.7 to 10% VS 10 to 50 %)
 
If coagulopathies that prevent sphincterotomy, or large stones, or too ill, can insert nasobiliary catheter.

Placing a stent  without first performing a sphincterotomy appears to permit adequate drainage and may be another option for patients with coagulopathies

 PTC involves transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. PTC permits a number of therapeutic interventions, including drainage of infected bile, extraction of biliary tract stones, dilation of benign biliary strictures, or placement of a stent across a malignant stricture.
Or placement of a percutaneous cholecystostomy tube in patients with an intact gallbladder.

 surgical exploration of the common bile duct for stone removal. Elective surgery carries a very low morbidity and mortality. If emergent surgery -choledochotomy with placement of a large-bore T tube has a lower mortality than cholecystectomy with common bile duct exploration.

Failure to perform a cholecystectomy, even after a sphincterotomy has been performed, is associated with high recurrence rates.

 Patients who are pregnant — same-antibiotic choices should take into account potential fetal toxicity . fetal shielding should be used.

mortality rates for patients with severe acute cholangitis remain high (20 to 30 percent)

PREVENTING RECURRENCE —  cholecystectomy is generally recommended.

If  benign stenosis, as is seen following bile duct injuries, endoscopic therapy or surgical repair may be required.
if malignant stenoses- typically with stent placement, though the specific therapy chosen will depend on the patient's life expectancy and the likelihood of stent occlusion.