Ascending Cholangitis

Done By: Abdullah Zuhair Alkhars Batch: 217 Contact Me At: Abdllhzk@gmail.com
Definition:
It Refers To Inflammation Of The CBD & Biliary Tree.
Pathogenesis:
It Starts With CBD Obstruction 2° To Postprandial Gallstone Ejection, Pancreatic/Biliary Carcinoma,
Post-Operative Strictures > The Bile Being Made In Liver And The Bile Stored In Gallbladder Would
No Longer Reach Duodenum When Pumped > This Causes (i) Bile Stasis With Consequent Chemical
Irritation To Biliary Tree (ii) Outflow Obstruction > Biliary Tree Won't Get Washed Out From Bowel
Ascending Microbes, Allowing E. coli, Klebsiella, Enterobacter, Enterococcus To Establish Infection.
(iii) Bile Accumulation In Hepatic Canaliculi, Leading To ↑ Pressure With Resultant Bile Infiltration
Into Plasma & High-Pressure Injury To Liver.
Clinical Manifestations (Charcot Triad):
(1) Fever & Rigors With Marked Weight loss.
(2) Postprandial RUQ Pain > 6H With N/V & (-) Murphy Sign.
(3) Obstructive Jaundice (Yellowish Discoloration & Pruritis & Dark Urine & Pale Stool) .
Complications:
(i) Biliary Strictures:
Cholangitis > Damage To The Biliary Tree Followed By Healing Process > Scarring "Strictures".
(i) Pyogenic Hepatic Abscess:
Obstructed CBD & Cholangitis > The Bile Being Made In The Liver And The Bile Stored In Gallbladder
Would No Longer Reach Duodenum When Pumped > Outflow Obstruction > Biliary Tree Won't Get
Washed Out From Bowel Ascending Microbes, Allowing E. coli (1st Most Common) & Klebsiella (2nd
Most Common) To Reach The Liver And Establish An Infection > Pyogenic Abscess > This's Normally
Reflected In The Form Of Swinging Fever, Malaise, RUQ Pain With Diaphragmatic Irritation, Tender
Hepatomegaly, And Sepsis. It Is A Very Serious Complication And Has A High Mortality Rate.
(i) Sepsis & Multiple Organ Failure:
Cholangitis > The Combined Effects Of (i) Bile Outflow Obstruction (iii) Edema 2° To Vasodilation &
High Permeability Dramatically ↑Intraluminal Pressure & Widen The Ductal Walls > This Leads To
Permeable Wall Across Which Bacteria Might Gain Access, Via The Underlying Blood Vessel, Into
Bloodstream > Sepsis With Consequent Hypotension & Altered Mental Status (Rapidly Fatal).
Note That Charcot Triad + Hypotension & Altered Mental Status = Reynolds Pentad.
DDx & Diagnosis:
The Differential Diagnosis Of RUQ Pain Associated With Jaundice & CBD Dilation Include:
(1) Biliary Strictures. (2) Head Of Pancreas Carcinoma. (3) CBD Stones & Cholangitis.
(4) Porta Hepatis Lymphadenopathy (Extrinsic Compression) . (5) Cholangiocarcinoma.
(6) Sphincter Of Oddi Dysfunction. (7) Urolithiasis/UTI. (8) Irritable Bowel Syndrome.
(9) Acute Hepatitis. (10) Early Appendicitis. (11) Peptic Ulcer. (12) Acute Pancreatitis.
Meanwhile, Ascending Cholangitis Is Clinical Diagnosis Supported Mainly By Imaging, As Follows:
(I) Imaging Techniques (To Establish Diagnosis):
(i) RUQ Ultrasound (Best Initial Test):
It Shows "Dilated CBD & Thickened Bile Duct Wall & Periductal Edema & Stone/Stricture/Tumor".
(ii) ERCP (Most Accurate Test & Therapeutic):
It Shows " Dilated CBD & Smooth-Walled Intraluminal Filling Defect Within The CBD & Etiology".
Note That, This Test Must Be Done After Stabilization Once Patient Has Been Afebrile For 48H, So
That The Underlying Cause Can Be Identified & A Proper Treatment Plan Can Be Tailored.
(II) Laboratory Tests (To Support Dx & Rule Out Complications):
(i) Complete Blood Count:
There'll Be Leukocytosis (Cholangitis > Cytokines & Toxins Induce Morrow To ↑ WBCs Synthesis) .
(ii) Liver Function Tests:
There'll Be ↑ ALT & AST (Cholangitis > Released By Damaged Ductal Cells & Hepatic Cells).
There'll Be ↑ Direct Bilirubin & GGT & ALP (CBD Obstruction > Released By Damaged Hepatic Cells).
(iii) Pancreatic Enzymes:
There'll Be ↑ Amylase & Lipase (CBD Obstruction > Released By Damaged Pancreatic Cells).
Treatment:
Best Initial Tx > ICU Admission With Close Monitoring Of Hemodynamics, Blood Pressure, Urinary
Output & Iv Fluid & Obtain Blood Culture Then Give Iv Broad-Spectrum Antibiotics.
Definitive Tx > Once The Patient Is Stabilized, CBD Decompression By ERCP ( Sphincterotomy) Or PTC
(Catheter Drainage) Or Laparoscopy (T-Tube Insertion); If However The Patient Isn't Responding To
Antibiotics, Perform Decompression Emergently.