Updated: 6/5/2019

Ascending Cholangitis

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Snapshot
  • A 56-year-old woman presents to the emergency room for skin discoloration, fevers, and abdominal pain. Her past medical history includes hyperlipidemia, obesity, diabetes, and gallstones. On physical exam, she is febrile, tachycardic, and jaundiced. She is tender to palpation in the right upper quadrant. She is alert and oriented with a normal mental status. Laboratory reveals markedly elevated alkaline phosphatase and white blood cell count. A right upper quadrant ultrasound shows intrahepatic biliary dilatation. She is started on broad-spectrum antibiotics and scheduled for an endoscopic retrograde cholangiopancreatography (ERCP).
Introduction
  • Clinical definition
    • ascending infection of biliary tree in the setting of biliary obstruction or stasis
  • Epidemiology
    • demographics
      • incidence of up to 2% in those with gallstones
    • risk factors
      • gallstones
      • female gender
      • age
      • obesity
  • Pathogenesis
    • obstruction in the biliary tree leads to stasis and bacterial overgrowth in the bile ducts, which are typically sterile
    • infectious agents are often gram-negative rods, Enterococcus, and anaerobes
Presentation
  • Symptoms
    • Charcot triad
      • jaundice
      • fever
      • right upper quadrant abdominal pain
    • Reynold pentad in severe cases
      • Charcot triad
      • altered mental status
      • septic shock
Studies
  • Diagnostic testing
    • imaging
      • right upper quadrant ultrasound
        • best initial imaging
        • findings
          • gallstones
          • biliary dilatation
      • magnetic resonance cholangiopancreatography (MRCP)
        • high sensitivity
        • may guide endoscopic vs surgical interventions
        • findings
          • dilated intrahepatic biliary ducts
    • studies
      • ↑ white blood cell count
      • ↑ alkaline phosphatase
      • ↑ total and direct bilirubin
      • mild ↑ liver enzymes
  • Diagnostic criteria
    • signs of systemic inflammation
      • fever
      • ↑ white blood cell count
    • cholestasis
      • jaundice
      • ↑ alkaline phosphatase or bilirubin
    • imaging findings
      • biliary dilatation
      • visualization of obstruction
Differential
  • Acute cholecystitis
    • distinguishing factor
      • may develop into ascending cholangitis
      • may or may not have ↑ alkaline phosphatase, ↑ bilirubin, or jaundice
Treatment
  • Management approach
    • ascending cholangitis is acutely managed with antibiotics and ERCP, but patients will eventually undergo cholecystectomy
  • First-line
    • antibiotics
      • drugs
        • broad spectrum, such as cefazolin or ceftriaxone
    • endoscopic retrograde cholangiopancreatography (ERCP)  
      • indication
        • all patients
        • intervention of choice
          • can include stone removal, stent placement, or sphincterotomy
  • Second-line
    • percutaneous drainage
      • indication
        • failure of ERCP
        • inability to perform ERCP
Complications
  • Hepatic abscesses
  • Portal vein thrombosis
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.42) A 76-year-old male is brought in by fire rescue to the emergency department. His history is notable for obesity, hypertension, and metabolic syndrome. His pulse is 115/min, blood pressure is 90/60 mmHg, respirations are 20/min, and SpO2 is 98%. The patient's sclera are notably icteric. He is disoriented and becomes agitated when his abdomen is palpated in the right upper quadrant. The patient is admitted to the intensive care unit for management. After initial stabilization with IV fluids and broad spectrum antibiotics, an MRCP is obtained after abdominal ultrasound demonstrates gallstones (shown in Figure A). Overnight, the patient becomes hemodynamically unstable and is started on vasopressor support. What is the most appropriate next step in management? Review Topic

QID: 103065
FIGURES:
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Rifaximin and lactulose

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Ursodeoxycholic acid

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Laparoscopic cholecystectomy

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Percutaneous cholecystostomy

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Exploratory laparotomy

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(M2.GI.4694) A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever. The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding. The patient is noticeably jaundiced. Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL. What is the diagnosis in this patient? Review Topic

QID: 107738
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Acute cholecystitis

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Acute pancreatitis

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Chronic pancreatitis

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Acute cholangitis

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Primary sclerosing cholangitis

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(M3.GI.10) A 40-year-old female visits the emergency department with right upper quadrant pain and fever of 2-hours duration. She denies alcohol, cigarette, and drug use and reports no other medical problems. Body mass index is 30 kg/m^2. Her temperature is 38.5 degrees Celsius (101.3 degrees Fahrenheit), blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 18/min. Jaundice is present in the sclera and at the base of the tongue. The abdomen is tender in the right upper quadrant. Liver function test (LFTs) reveal elevated direct and total bilirubin and alkaline phosphatase of 500 U/L. IV Ampicillin-gentamicin is administered, fluid resuscitation is initiated, and over 24 hours the patient’s fever improves. Which of the following is the next step in the management of this patient: Review Topic

QID: 103033
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Elective laparoscopic cholecystectomy

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Urgent open cholecystectomy

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Endoscopic retrograde cholangiopancreatography (ERCP)

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Administer bile acids

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Extracorporeal shock wave lithotripsy

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