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Gastrointestinal (GI) System

Ascending cholangitis

Infections involving the biliary system and leading to inflammation and obstruction of the biliary ducts

Infections involving the biliary system and leading to inflammation and obstruction of the biliary ducts

  • GASTROENTEROLOGIC EMERGENCY

History

Dr Jean-Martin Charcot, working at the Salpêtrière Hospital in Paris, France, is credited with early reports of cholangitis, as well as his eponymous triad, in 1877. He referred to the condition as “hepatic fever” (fièvre hépatique). Dr Benedict M. Reynolds, an American surgeon, reignited interest in the condition in his 1959 report with colleague Dr Everett L. Dargan, and formulated the pentad that carries his name. It remained a condition generally treated by surgeons, with exploration of the bile duct and excision of gallstones, until the ascendancy of ERCP in 1968. ERCP is generally performed by internal medicine or gastroenterology specialists. In 1992 it was shown that ERCP was generally safer than surgical intervention in ascending cholangitis.

Jean-Martin Charcot
Jean-Martin Charcot (1825 – 1893) was a French neurologist and professor of anatomical pathology. He is best known today for his work on hypnosis and hysteria, in particular his work with his hysteria patient Louise Augustine Gleizes. Also known as “the founder of modern neurology”, his name has been associated with at least 15 medical eponyms, including Charcot–Marie–Tooth disease and Charcot disease. Charcot has been referred to as “the father of French neurology and one of the world’s pioneers of neurology”. His work greatly influenced the developing fields of neurology and psychology; modern psychiatry owes much to the work of Charcot and his direct followers. He was the “foremost neurologist of late nineteenth-century France” and has been called “the Napoleon of the neuroses”.

Etiology

Cholangitis:

  • Primary sclerosing cholangitis (PSC)
  • Secondary cholangitis: Ascending/suppurative cholangitis (M/C)
  • Immune cholangitis: IgG4-associated cholangitis (IAC)

Ascending cholangitis:

  • Choledocholithiasis (M/C cause)
  • Congenital factors
  • Post-operative factors (bile duct injury, bilio-enteric anastomosis strictures, sump syndrome)
  • Inflammatory factors (parasitic infection, oriental cholangitis)
  • Malignant strictures (bile duct, gallbladder, ampullary, pancreatic malignancy)
  • Duodenal tumours
  • Pancreatitis
  • External compression, e.g. pericholecystic inflammatory changes, Mirizzi syndrome
  • Papillary stenosis
  • Duodenal diverticulum/Lemmel syndrome

Pathophysiology

Characterized by acute inflammation and infection of the bile duct system with increased bacterial loads (biliary infection) and high intraductal pressure levels (biliary obstruction) favouring bacterial and endotoxin translocation into the vascular and lymphatic drainage (concept of cholangiovenous and cholangiolymphatic reflux, respectively).

In conjunction with an increased permeability of the acutely inflamed biliary epithelium, the stage is set for potentially fatal complications such as biliary sepsis and hepatic abscess.

Ascending cholangitis: Pathogenesis & clinical findings
The Calgary Guide | http://calgaryguide.ucalgary.ca/

Charcot’s triad:

  • Intermittent fever (90% cases)
  • Right upper quadrant (RUQ) pain
  • Jaundice (60-70% cases)

Reynolds’ pentad (indicative of ongoing biliary sepsis):

  • Charcot’s triad
  • Lethargy/mental confusion
  • Septic shock

Diagnosis

Diagnostic criteria:

Diagnostic algorithm in acute bacterial cholangitis
Diagnostic algorithm in acute bacterial cholangitis. ERC = Endoscopic retrograde cholangiography; WBC = white blood cell; CRP = C-reactive protein; AP = alkaline phosphatase; γGT = γ-glutamyltransferase; ASAT = aspartate aminotransferase; ALAT = alanine aminotransferase. | Zimmer, V., & Lammert, F. (2015). Acute Bacterial Cholangitis. Viszeralmedizin, 31(3), 166–172. https://doi.org/10.1159/000430965

Imaging

  • Abdominal ultrasound (USG)
  • Endoscopic ultrasound (EUS)
  • Magnetic resonance cholangiopancreatography (MRCP)
  • CT-scan
  • Endoscopic retrograde cholangiography (ERCP) (GOLD STANDARD): Complete assessment of a ductal tree, showing the presence of obstructive lesions and stenosis

Management

Treatment is directed at 2 main pathophysiologic components of acute cholangitis: biliary infection (systemic antibiotic treatment) and obstruction (biliary drainage)

In addition, appropriate supportive care has to be administered, in more severe cases in an intensive care setting with the option of providing adequate organ support if necessary.

Hospitalization is usually considered necessary even for patients with mild acute cholangitis.

Clinical TG13 flowchart for the management of acute cholangitis
Clinical TG13 flowchart for the management of acute cholangitis | Miura F, Takada T, Strasberg SM, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:47–54.

Antibiotic treatment:

  • IV fluid resuscitation
  • AntibioticsTicarcillin + clavulanante (Timentin) or piperacillin + tazobactam (Tazocin)

Biliary drainage:

  • Surgical drainage
  • Percutaneous transhepatic biliary drainage (PTBD)
  • Endocscopic drainage (FIRST-LINE)
    • EUS-guided biliary drainage (EUS-BD) (FIRST LINE THERAPY)
      • EUS-guided choledo-choduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD)
    • ERCP

Supportive care:

More important in severe cases
  • Invasive monitoring
  • Intensive care setting
  • Inotropic and ventilation support

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