Ascending Cholangitis Management

1. J O H N N Y I L I F F
ASCENDING
CHOLANGITIS

2. ANATOMY

3. CLINICALLY

4. CLINICALLY
• Charcot's triad consists of fever, RUQ pain, and
jaundice (50%-75%- have all three)
• Reynolds pentad adds mental status changes and
sepsis to the triad
• Fever is present in approximately 90% of cases.
• Abdominal pain and jaundice is thought to occur in
70% and 60% of patients, respectively.
• Obs

5. HISTORY
• Gallstones, CBD stones (28%-70%)
• Recent cholecystectomy
• Endoscopic manipulation or ERCP, cholangiogram
• History of cholangitis
• Immunocompromised
• Malignancy (10-57%)
• Sepsis
• Hypotension (30%)- has been reported as the only
symptom in patients on glucocorticoids
• Tachycardia

6. • Biilary obstruction and stasis

7. THE BUGS
• Escherichia coli (27%-50%)Gram Neg
• Klebsiella species (16%-20%)Gram Neg
• Enterococcus species (15%)Gram Pos
• Streptococcus species (8%)
• Enterobacter species (5-10%)
• Pseudomonas aeruginosa (7%).

8. HOW DO THEY GET THERE?
• Disruption of normal barriers
• May result in translocation of bacteria from portal
system or duodenum into biliary tree (sphincter of
oddi)
• Increase intrabilary pressure increased
permeability of bile ductules thus permitting
translocation of the bacteria and toxins
• Also favours migration of bacteria from bile into
systemic circulation

9. NORMAL PREVENTATIVE MEASURES
• Continuous bile flushing
• Secretory IgA
• Kupffer cells

10. TREATMENT
• ABC
• CODE SPESIS
• Early Fluids
• IV Abx within 1 hour- gold standard as per Surviving Sepsis
Guidelines
• Cover for Gram Neg- most important
• Start Broad
• amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly
PLUS
gentamicin 4 to 6 mg/kg (child <10 years: 7.5 mg/kg; >10 years: 6
mg/kg) IV, daily
for up to 3 days (adjust dose for renal function)
• 3rd Gen Ceph if immediate hypersensitivity

11. ABC

12. THE BOSS SAYS
• Airway
• Breathing
• Circulation
• Code Sepsis

13. TREATMENT
• ABC
• CODE SPESIS
• Early Fluids
• IV Abx within 1 hour- gold standard as per Surviving Sepsis
Guidelines
• Cover for Gram Neg- most important
• Start Broad
• amoxy/ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly
PLUS
gentamicin 4 to 6 mg/kg (child <10 years: 7.5 mg/kg; >10 years: 6
mg/kg) IV, daily
for up to 3 days (adjust dose for renal function)
• 3rd Gen Ceph if immediate hypersensitivity

14. DIFFERENTIALS
• Biliary Leak
• Cholecystitis
• Pancreatitis
• Liver Abscess
• Infected Choledochal cyst
• Recurrent Pyogenic cholangitis
• Mirizzi syndrome
• RLL pneumonia
• Biliary Tree Malignancy

15. INVESTIGAITONS
• Bloods- FBC, U+E, COAG, LFTs, ALT, Lipase, CRP,
cultures
• CXR- ? Perf- unlikely
• U/S
• CT Abdo- if diagnosis unclear- potential malignancy
• MRCP

16. DEFINITIVE INPATIENT TREAMENT
• Continue IV ABX 7-10 days
• Biliary Drainage- Endoscopic Sphincterotomy +/-
stone retrieval via ERCP
• Adjust Abx depending on response/ cultures
• If worsening can consider Tazocin
• Discuss with microbiology

17. • 70-80% respond to IV ABX as conservatively managed
patients initially
• ECRP 24-48hours after presentation (90%-95% success)
Percutaneous transhepatic cholangiography PTC or
open surgical decompression
• If more than 2cm- lithotripsy
• If not improving- urgent surgical decompression severe
acute suppurative cholangitis
• Risk factors in those with CBD stone
- Smoker, impacted stone, 70+, further GB stones

18. DEFINITIVE TREATMENT OF CAUSE
• Cholecystectomy
• Stent
• Urgent decompression-
- Persistent abdo pain
- Hypotension despite adequate resus
- Fever >39.0*C
- Confusion/ delerium

19. But Doc shes pregnant!!!

20. PREGANANCY
• Adjust Abs and treat

21. PROGNOSIS
• Highly variable mortality rates in literature (20%-30%
current literature)
• Prevent recurrence- stenting/surgery etc

22. OPINION OF THE SURGEONS
• Ensure quick IVAbs- within 1 hour and ensure Gastro
are aware
• Keep doing what we are doing!

23. OPINION OF THE
GASTROENTEROLOGISTS
• Quick IVAbs

24. • http://emedicine.medscape.com/article/774245-
overview#a0199
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