Cholangitis

Etiology and pathophysiology

  • – Choledocholithiasis : 85% cases
  • – Other causes of bile duct obstruction
  • – Neoplasm
  • – Biliary stricture
  • – Parasitic infections
  • – Congenital abnormalities of bile ducts
  • – 15% neoplastic bile duct lesion may present with cholangitis
  • – The bacterial species most commonly cultured from the bile are coli, Klebsiella, Pseudomonas, Proteus, and enterococci

Clinical features:

  • – Charcot’s triad: RUQ pain, jaundice, and fever present in 70% patients
  • – Reynolds’ pentad: Charcot’s triad + hypotension + altered mental status
  • – Liver abscess may develop in overlooked severe cholangitis

Investigations:

  • – Elevated WBC
  • – Bilirubin >2 mg/dl, Raised ALP
  • – Blood culture
  • – Imaging
  •            USG:
  •                  • Bile duct stone found in 50% cases, dilated bile duct 75% cases
  •                  • Normal US findings do not exclude the possibility of choledocholithiasis in a patient in whom the clinical presentation suggests cholangitis
  •            CT scan:
  •                • To exclude complications of gall stone (Pancreatitis, pancreatic abscess)
  • Treatment of cholangitis:
  • – Blood culture should be done immediately
  • – Antibiotic Should be started against likely organism

Mild cholangitis

  • – Single drug is sufficient
  • Choice of drug: Cefoxitin 2.0 g I.V 6-8 hourly

Severe cholangitis:

  • – More intensive therapy with
  •              • Gentamicin
  •              • Ampicillin
  •              • Metronidazole or
  •              • Piperacilin-Tezobactam 3.375 g I.V 6 hourly
  •              • Meropenem if resistant organism is suspected
  • – Patients condition usually improve within 6-12 hours
  • – Infection comes under control within 2-3 days with defervescence, relief of discomfort, decline of WBC
  • – Biliary decompression should be done if patients condition deteriorates after 6-12 hour observation
  •            • Biliary decompression done by
  •                             ◊ ERCP with stone extraction
  •                            ◊ Intrabiliary stent insertion

 


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