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Updated: Dec 14 2021

Ascending Cholangitis

  • 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
  • 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
    • Diagnostic testing
      • 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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