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Ascending Cholangitis

Ascending or acute cholangitis is a potentially life-threatening bacterial infection of the biliary tree that stems from bile duct obstruction and ascension of bacteria from the intestinal tract. Principal symptoms include abdominal pain, fever, and jaundice, known as the Charcot's triad, but additional clinical signs, as well as imaging studies, are necessary to confirm the diagnosis.


Presentation

Signs and symptoms of ascending cholangitis (also known as acute cholangitis) develop due to the obstruction of the biliary tree (by gallstones or choledocholithiasis, tumors or benign strictures are known as pathogenic mechanisms) and secondary bacterial colonization of the bile ducts from the gastrointestinal tract or the portal venous system [1] [2]. As a result, bacteria are able to reproduce and proliferate in this tight environment (as bile is not capable of flushing them back into the duodenum along its pathway), causing an intense inflammatory reaction and symptoms of abdominal pain, jaundice and fever, known as the Charcot's triad [3] [4] [5]. Although this clinical entity was described more than 100 years ago, most recent guidelines have proposed the exclusion of abdominal pain from constitutive features of acute cholangitis, because of a rather low report rate by patients [5] [6]. Indeed, the presence of a complete Charcot's triad ranges from 15.4–72.0%, which is why fever and jaundice remain the most important features [4]. Ascending cholangitis is life-threatening, with mortality rates being 2.5-3.5%, but in the absence of an early diagnosis, dissemination of bacteria in the systemic circulation and sepsis can occur, in which case mortality rates rise to 84-100% without immediate initiation of directed therapy [3] [5] [7]. In fact, septic encephalopathy is seen in up to 9% of cholangitis patients and is manifested as loss of consciousness and shock in most severe cases [5] [7]. Furthermore, some authors add hypotension and altered mental status to the Charcot triad's to form the Reynold's pentad, another diagnostic tool used to identify patients with ascending cholangitis [3] [8].

Fever
  • Indeed, the presence of a complete Charcot's triad ranges from 15.4–72.0%, which is why fever and jaundice remain the most important features.[symptoma.com]
  • Fever and Skin Rash 292 Fever and the Renal Transplant Recipient 301 Fever Following Travel Abroad 306 Hyperpyrexia and Hyperthermia 316 Fever in the Granulocytopenic Patient 319 Fever of Unknown Origin 325 Recurrent Furunculosis 333 Postoperative Fever[books.google.com]
  • Signs and symptoms include fever, pain, and increased serum bilirubin levels.[ncbi.nlm.nih.gov]
  • […] chol·an·gi·tis len·ta low-grade bacterial infection of the biliary tract; sometimes causes fever of unknown origin. ascending cholangitis Acute bile duct inflammation.[medical-dictionary.thefreedictionary.com]
  • One of the main causes of ascending cholangitis is bacteria, resulting in symptoms such as fever, jaundice and pain.[diethealthclub.com]
Chills
  • Clinical findings Right upper quadrant pain that may radiate to the shoulder, variable severity, nausea, vomiting, constipation, episodic chills, fever, slow pulse, Murphy sign, anorexia, weight loss; spontaneous remission is rare.[medical-dictionary.thefreedictionary.com]
  • SYNONYMS Biliary sepsis Ascending cholangitis Suppurative cholangitis SYMPTOMS Pain, chills, and jaundice ( Charcot triad ) are the cardinal symptoms of cholangitis. Pain may be absent.[encyclopedia.lubopitko-bg.com]
  • […] liver abscesses Sclerosing cholangits is due to progressive inflammation of the billiary tree commonly in patients with choledocholithiasis or IBD Presentation Symptoms present with Charcot's Triad (85% senstive for cholangitis) RUQ pain jaundice fever/chills[medbullets.com]
  • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice). Primary sclerosing cholangitis signs or symptoms may not be seen in the early stages.[diethealthclub.com]
  • […] coli, Klebsiella, Streptococcus, Enterobacter, Pseudomonas Other causes: HIV/AIDS cholangiopathy, parasitic infections (Ascaris lumbricoides) Presentation Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific) Symptoms Fever/chills[coreem.net]
Rigor
  • Presentation – rigors, fever, abdominal pain, jaundice Treatment It is a medical emergency.[almostadoctor.co.uk]
Abdominal Pain
  • Principal symptoms include abdominal pain, fever, and jaundice, known as the Charcot's triad, but additional clinical signs, as well as imaging studies, are necessary to confirm the diagnosis.[symptoma.com]
  • A 73-year-old man with abdominal pain and vomiting was admitted to the emergency room. His medical history was significant for subtotal gastrectomy with Billroth II anastomosis for benign gastric ulcer perforation 40 years prior.[ncbi.nlm.nih.gov]
  • For Additional Reading: Cholangitis: Pearls & Pitfalls Cholangitis: Deadly Cause of Right Upper Quadrant Abdominal Pain Cholangitis: Deadly Cause of Right Upper Quadrant Abdominal Pain[emdocs.net]
  • Presents with abdominal pain, fever, and obstructive Liver Function Tests (LFTs). Radiographic findings: Early Findings: none except for obstruction. Late Findings: pleating or wall irregularity; mural necrosis; intrahepatic abscesses at duct ends.[med-ed.virginia.edu]
  • Initial Presentation: Jaundice Abdominal pain Fever Vital Signs: Fever can be present given this is an infectious process Dermatological Exam: Scleral icterus Jaundice Abdominal Exam: Abdominal tenderness: can commonly be in the right upper quadrant.[stepwards.com]
Nausea
  • Clinical findings Right upper quadrant pain that may radiate to the shoulder, variable severity, nausea, vomiting, constipation, episodic chills, fever, slow pulse, Murphy sign, anorexia, weight loss; spontaneous remission is rare.[medical-dictionary.thefreedictionary.com]
  • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice). Primary sclerosing cholangitis signs or symptoms may not be seen in the early stages.[diethealthclub.com]
  • Charcot’s triad (fever, right upper quadrant pain, and jaundice) is present in 56-70% of patients. 1 Individuals with ascending cholangitis frequently report mild abdominal pain and nausea.[emdocs.net]
  • The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain. Choledocholithiasis – gallstones in the common bile duct.[sketchymedicine.com]
  • Klebsiella, Streptococcus, Enterobacter, Pseudomonas Other causes: HIV/AIDS cholangiopathy, parasitic infections (Ascaris lumbricoides) Presentation Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific) Symptoms Fever/chills Nausea[coreem.net]
Vomiting
  • A 73-year-old man with abdominal pain and vomiting was admitted to the emergency room. His medical history was significant for subtotal gastrectomy with Billroth II anastomosis for benign gastric ulcer perforation 40 years prior.[ncbi.nlm.nih.gov]
  • Clinical findings Right upper quadrant pain that may radiate to the shoulder, variable severity, nausea, vomiting, constipation, episodic chills, fever, slow pulse, Murphy sign, anorexia, weight loss; spontaneous remission is rare.[medical-dictionary.thefreedictionary.com]
  • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice). Primary sclerosing cholangitis signs or symptoms may not be seen in the early stages.[diethealthclub.com]
  • The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain. Choledocholithiasis – gallstones in the common bile duct.[sketchymedicine.com]
  • Klebsiella, Streptococcus, Enterobacter, Pseudomonas Other causes: HIV/AIDS cholangiopathy, parasitic infections (Ascaris lumbricoides) Presentation Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific) Symptoms Fever/chills Nausea/vomiting[coreem.net]
Epigastric Pain
  • C H I E F C O M P L A I N T Patient had fever and complaint of epigastric pain prompting immediately his family members to consult. The client was weak and pale in appearance and noted to have facial grimacing.[scribd.com]
  • pain/ total and direct bilirubin elevated as well as alkaline phosphatase/ can lead to cholangitis/ usg done but cant proficiently see CBD so gold standard is ERCP cholangitis: infection / deadly RUQ pain jaundice fever(very ill patient) septic shock[usmleforum.com]
  • pain Nausea and vomiting are the next most frequently seen features Only about 30% have a fever Rebound tenderness is only present in about 30-50% Rigidity and guarding is only present in 30% Diagnostic tests Diagnostic biochemistry These diagnostic[derangedphysiology.com]
Clay-Colored Stool
  • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice). Primary sclerosing cholangitis signs or symptoms may not be seen in the early stages.[diethealthclub.com]
  • Dark urine and clay-colored stools. Nausea and vomiting. Yellowing of the skin (jaundice), which may come and go. Quick diagnosis and treatment are very important. Antibiotics to cure infection are the first treatment done in most cases.[medlineplus.gov]
Hypotension
  • In the more severe, life-threatening form, known as toxic cholangitis or cholangitis with sepsis, patients have purulent biliary tree contents, as well as evidence of sepsis, hypotension, multi-organ failure, and mental status changes. [1] Boey JH, Way[bestpractice.bmj.com]
  • A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated.[ncbi.nlm.nih.gov]
  • Furthermore, some authors add hypotension and altered mental status to the Charcot triad's to form the Reynold's pentad, another diagnostic tool used to identify patients with ascending cholangitis.[symptoma.com]
  • 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[slideshare.net]
  • In addition to pain/fever/ jaundice, hypotension and mental status changes are seen in this more severe variety of ascending cholangitis. This was the first time I've seen manifestations of Reynaud's Pentad in an actual patient.....[buckeyesurgeon.com]
Tachycardia
  • 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[slideshare.net]
  • […] lumbricoides) Presentation Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific) Symptoms Fever/chills Nausea/vomiting Abdominal pain Physical Exam RUQ tenderness to palpation Peritoneal signs are variable Jaundice Frank sepsis (fever, tachycardia[coreem.net]
  • […] cholecystectomy ERCP or cholangiogram previous cholangitis immunocompromise malignancy CLINICAL FEATURES History fever ( 80%) abdominal pain (especially RUQ) ( 80%) nausea and vomiting, malaise predisposing factors and history of an underlying cause Examination tachycardia[lifeinthefastlane.com]
  • Physical signs may include fever, right upper quadrant tenderness, jaundice, mental status changes, hypotension and tachycardia. Peritonism is an unusual sign and should stimulate the search for an alternative diagnosis.[patient.info]
  • […] management Pancreas Pancreatic and hepatic surgery Pancreatic cancer Paraneoplastic syndromes Parapsoriasis Parasympathomimetic drugs Parenteral anticoagulation Parenteral fluid therapy Parkinson disease Parkinson-plus syndromes Paroxysmal supraventricular tachycardia[amboss.com]
Slow Pulse
  • Clinical findings Right upper quadrant pain that may radiate to the shoulder, variable severity, nausea, vomiting, constipation, episodic chills, fever, slow pulse, Murphy sign, anorexia, weight loss; spontaneous remission is rare.[medical-dictionary.thefreedictionary.com]
Jaundice
  • Indeed, the presence of a complete Charcot's triad ranges from 15.4–72.0%, which is why fever and jaundice remain the most important features.[symptoma.com]
  • : stone in CBD/ obstructive jaundice(jaundice is big thing here)/ RUQ or epigastric pain/ total and direct bilirubin elevated as well as alkaline phosphatase/ can lead to cholangitis/ usg done but cant proficiently see CBD so gold standard is ERCP cholangitis[usmleforum.com]
  • We seen patients jaundiced with common duct stones quite frequently in surgical practice but it's quite rare for a patient to progress so quickly to septic shock.[buckeyesurgeon.com]
  • One of the main causes of ascending cholangitis is bacteria, resulting in symptoms such as fever, jaundice and pain.[diethealthclub.com]
  • A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction.[ncbi.nlm.nih.gov]
Biliary Colic
  • Compare & contrast the S & Sx of RUQ P, fever/ WCC, & jaundice in biliary colic, acute cholecystitis, & cholangitis.[goconqr.com]
  • Depending on what the cause of your cholangitis is you could exhibit some of these symptoms: Pain in the upper right side of the abdomen Biliary colic Biliary colic post a fatty meal Pain near the right shoulder blade Discomfort in the abdomen and flatulence[diethealthclub.com]
  • Run of the mill biliary colic can be managed as an outpatient. Even patients with acute cholecystitis can be cooled down for 24-48 hours with fluids and IV antibiotics prior to definitive surgery.[buckeyesurgeon.com]
  • colic • Acute cholecystitis • Liver abscess • PUD • Pancreatitis • Intestinal obstruction • Right kidney stone • Hepatitis • Pyelonephritis WORKUP • Blood cultures • CBC • Liver function tests LABORATORY TESTS • Usually, elevated WBC count with a predominance[encyclopedia.lubopitko-bg.com]
Scleral Icterus
  • Initial Presentation: Jaundice Abdominal pain Fever Vital Signs: Fever can be present given this is an infectious process Dermatological Exam: Scleral icterus Jaundice Abdominal Exam: Abdominal tenderness: can commonly be in the right upper quadrant.[stepwards.com]
  • She has scleral icterus and jaundice (worsened per family). The patient grimaces on palpation of the right upper quadrant. Initial VS: BP 90/68, HR 147, T 103.2 Rectal, RR 24, SpO2 95% on room air.[emdocs.net]
Pruritus
  • The patient may also report acholic (putty-coloured) stools and pruritus. A history of gallstones, CBD stones, recent cholecystectomy, ERCP or other invasive procedures, HIV or AIDS may assist the diagnosis.[patient.info]
  • […] sclerosing cholangitis Principles of coronary heart disease Principles of dermatology Principles of medical law and ethics Progressive muscular dystrophies Prostate cancer Prostatitis Protein analysis Proteins and peptides Proteinuria Proton pump inhibitors Pruritus[amboss.com]
Dark Urine
  • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice). Primary sclerosing cholangitis signs or symptoms may not be seen in the early stages.[diethealthclub.com]
  • Obstruction of the biliary system can hinder excretion of bilirubin into the gut and simultaneously exceed the processing ability of the kidneys, leading to pale stools and dark urine.[accessmedicine.mhmedical.com]
  • Dark urine and clay-colored stools. Nausea and vomiting. Yellowing of the skin (jaundice), which may come and go. Quick diagnosis and treatment are very important. Antibiotics to cure infection are the first treatment done in most cases.[medlineplus.gov]
  • She was nauseated and had dark urine. On initial assessment, she was deeply icteric and her temperature was 38.2 C but she was haemodynamically stable.[jmedicalcasereports.biomedcentral.com]

Workup

Acute deterioration of patients that present with jaundice and fever (as well as abdominal pain) must raise clinical suspicion of an inflammatory process in the biliary tree, especially if loss of consciousness or an altered mental state is also present [3]. After obtaining a detailed patient history (if patients are unconscious, friends or family who bring the patient to the hospital can provide valuable information). Conducting a thorough physical examination and a complete laboratory workup is mandatory. A complete blood count (CBC) will almost always show leukocytosis [5], whereas inflammatory parameters - C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fibrinogen will all be elevated depending on the duration and severity of the infection. Alkaline phosphatase (ALP), bilirubin, and pancreatic amylase levels may be elevated in severe cases [8]. At the same time, blood cultures should be drawn, and they are likely to be positive in the majority of the cases [5]. Bacterial pathogens that cause ascending cholangitis are principally gram-negative Enterobacteriaceae (Escherichia coli, Enterobacter spp, and Klebsiella spp), while gram-positive microorganisms (eg. Enterococcus sp) and anaerobes (Bacteroides spp, Clostridia, and Fusobacterium spp) are less common [8]. On the other hand, imaging studies must be performed early on, including ultrasonography and computed tomography (CT), which is recommended as a first-line procedure [4]. Multidetector CT (MDCT) has shown even greater specificity and sensitivity and should be performed whenever possible, while magnetic resonance cholangiopancreatography (MRCP) is also mentioned as a reliable method to diagnose the condition [3] [4].

Candida
  • After fistula formation, we could successfully treat the inflammation caused by infection of Citrobacter freundii and Candida albicans with intravenous infusion of both antibiotic and antifungal agents.[ncbi.nlm.nih.gov]

Treatment

  • It is unclear as to which type of the fistula needs surgical treatment.[ncbi.nlm.nih.gov]
  • Optimal treatment is complete tumor resection. A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction.[ncbi.nlm.nih.gov]
  • Nurses need to be aware of the clinical manifestations of AAC to ensure timely treatment of this sometimes fatal event.[ncbi.nlm.nih.gov]
  • Antibiotics alone do not provide sufficient treatment in the majority of patients. Drainage of the biliary tree is the most critical step in management.[blood-test.biz]
  • Cholangitis Treatment It is important that cholangitis is diagnosed in time and appropriate treatment be administered. In the initial stages cholangitis, treatment guidelines recommend that antibiotics be used to treat the problem.[diethealthclub.com]

Prognosis

  • Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.[ncbi.nlm.nih.gov]
  • PROGNOSIS • Highly variable mortality rates in literature (20%-30% current literature) • Prevent recurrence- stenting/surgery etc 22.[slideshare.net]
  • DISPOSITION Excellent prognosis if obstruction is amenable to definitive surgical therapy; otherwise relapses are common. DON'T FORGET - KNOWLEDGE IS EVERYTHING![encyclopedia.lubopitko-bg.com]
  • It may worsen the prognosis, with an increase in mortality, secondary failure of restoration of bile flow, and possible exacerbation of portal hypertension.[clinicaltrials.gov]
  • After acute episode is controled: ERCP should be performed to locate the cause of the obstruction followed by stone removal, stent placement, or sphincterotomy Prognosis, Prevention, and Comlications 90% mortality rate in untreated patients. E.[medbullets.com]

Etiology

  • Other etiologies include strictures and tumors. The bile flow is stanched and the patient will become jaundiced.[buckeyesurgeon.com]
  • Hepatic abscess and pancreatitis ETIOLOGY Obstruction of the common bile duct causing rapid proliferation of bacteria in the biliary tree • Most common cause of common bile duct obstruction: stones, usually migrated from the gallbladder[encyclopedia.lubopitko-bg.com]
  • […] s/p antibiotics and fluid resuscitation decompression scheduled prior to hospital discharge 2 Pearls: Severe abdominal pain is uncommon in the setting of ascending cholangitis consider pancreatitis, cholecystitis, or perforated viscus as alternative etiologies[emdocs.net]
  • Imaging Biliary dilatation Evidence of the etiology upon imaging (stricture, stone, stent, etc.)[derangedphysiology.com]
  • Etiology immunity / dysimmunity acute rejection of liver allograft Kawasaki disease viral infections Cytomegalovirus (neonate) bacterial infections Salmonellosis Syphilis, secondary Toxic shock syndrome Tuberculosis Pyogenic abscess Reactive changes,[humpath.com]

Epidemiology

  • EPIDEMIOLOGY & DEMOGRAPHICS INCIDENCE (IN U.S.): Complicates approximately 2% of cases of cholelithiasis • Other causes: prior biliary tract surgery with secondary stenosis, tumor (usually arising from the pancreas or biliary tree), and parasitic infections[encyclopedia.lubopitko-bg.com]
  • Epidemiology: Reportedly occurs in 50,000-75,000 individuals in the U.S. annually; mortality estimated as 5%. 1 Presentation: Fever is the most common presenting symptom (90% of cases 1 ).[emdocs.net]
  • Epidemiology [ 1 ] Up to 9% of patients admitted to hospital with gallstone disease have acute cholangitis [ 3 ]. Approximately 1% of patients develop cholangitis after ERCP [ 4 ].[patient.info]
  • The epidemiology of gallstones in a 70-year-old Danish population . Scand. J. Gastroenterol. 25 , 335–340 (1990). 5. The MICOL Group.[nature.com]
  • […] intracranial pressure and brain herniation Elimination disorders Embryogenesis Emotional and behavioral disorders in children and adolescents Endarterectomy Endometrial cancer Endometriosis Endophthalmitis Environmental injuries Enzymes and biocatalysis Epidemiology[amboss.com]
Sex distribution
Age distribution

Pathophysiology

  • Mortality rate 5-10% Hepatobiliary Tract Anatomy Pathophysiology Bile duct develops an obstruction Obstruction may be incomplete (more common) or complete Causes: Gallstones (most common), malignancy, benign stricture, iatrogenic (i.e.[coreem.net]
  • Role of the gut in the pathophysiology of extrahepatic biliary obstruction . Gut 39 , 587–593 (1996). 20. Raper, S. E. , Barker, M. E. , Jones, A. L. & Way, L. A. Anatomic correlates of bacterial cholangiovenous reflux .[nature.com]

Prevention

  • Backwash of bowel contents was reduced and further cholangitis was prevented by creation of an on-line intussuscepted Roux-en-Y jejunal loop to provide a nonrefluxing conduit from the porta hepatis.[ncbi.nlm.nih.gov]
  • Abstract An intussusceptive antireflux valve was created in the Roux-en-Y loop at the same time as the hepatic portojejunostomy (Kasai procedure) for the purpose of preventing ascending cholangitis in 14 new cases of biliary atresia and in 6 long-term[ncbi.nlm.nih.gov]
  • Abstract An intussusception-type antireflux valve was created in the Roux-en-Y loop in 23 infants with biliary atresia (17 new cases, and six others after episodes of ascending cholangitis) and 10 patients with congenital bile duct dilatation, in order to prevent[ncbi.nlm.nih.gov]
  • […] of Influenza 480 AIDS 78 Transmission and Prevention of HIV Infection 489 Primary HIV infection 496 Treatment of Pneumocystis Carinii Pneumonia in AIDS 499 HIV1 and Infections of the Central Nervous System 504 Fever in the HIVinfected Patient 516 Prevention[books.google.com]
  • Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence.[indiana.pure.elsevier.com]

References

Article

  1. Mosler P. Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep. 2011;13(2):166-172.
  2. Kiriyama S, Takada T, Strasberg SM, et al. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci. 2012;19(5):548-556.
  3. Schneider J, Hapfelmeier A, Thöres S, et al. Mortality Risk for Acute Cholangitis (MAC): a risk prediction model for in-hospital mortality in patients with acute cholangitis. BMC Gastroenterol 2016;16:15.
  4. Yamamoto K Gotoda T, Kusano C, Liu J, Yasuda T, Itoi T, Moriyasu F. Severe Acute Cholangitis with Complications of Bacterial Meningitis Associated with Hearing Loss. Intern Med. 2015;54(14):1757-1760.
  5. Qin YS, Li QY, Yang FC, Zheng SS. Risk factors and incidence of acute pyogenic cholangitis. Hepatobiliary Pancreat Dis Int. 2012;11(6):650-654.
  6. Kim SW, Shin HC, Kim HC, Hong MJ, Kim IY. Diagnostic performance of multidetector CT for acute cholangitis: evaluation of a CT scoring method. Br J Radiol. 2012;85(1014):770-777.
  7. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
  8. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.

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Last updated: 2018-06-22 01:55