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].

Skin
Pruritus
  • Other symptoms include the following: Jaundice Fever, chills, and rigors Abdominal pain Pruritus Acholic or hypocholic stools Malaise The patient's medical history may be helpful.[emedicine.medscape.com]
  • The patient may also report acholic (putty-coloured) stools and pruritus.[patient.info]
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  • urogenital
    Dark Urine
    • She was nauseated and had dark urine.[jmedicalcasereports.biomedcentral.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.[medlineplus.gov]
    • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice).[diethealthclub.com]
    • Typically, an attack of colic is followed the next day by fluctuating jaundice, dark urine, pale stools, nausea and vomiting, fever and rigors, and a leucocytosis.[meb.uni-bonn.de]
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  • cardiovascular
    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]
    • DEFINITIVE TREATMENT OF CAUSE • Cholecystectomy • Stent • Urgent decompression- - Persistent abdo pain - Hypotension despite adequate resus - Fever 39.0*C - Confusion/ delerium 19.[slideshare.net]
    • A minority of patients present in shock with hypotension and altered mentation.[ncbi.nlm.nih.gov]
    • Question 9 from the second paper of 2016 presented the candidates with a scenario of an elderly woman with jaundice, confusion, hypotension, fever and abdominal pain.[derangedphysiology.com]
    • In addition to pain/fever/ jaundice, hypotension and mental status changes are seen in this more severe variety of ascending cholangitis.[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]
    • Physical examination may reveal the following: Fever (90%), although elderly patients may have no fever RUQ tenderness (65%) Mild hepatomegaly Jaundice (60%) Mental status changes (10-20%) Sepsis Hypotension (30%) Tachycardia Peritonitis (uncommon, and[emedicine.medscape.com]
    • […] 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.[patient.info]
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  • gastrointestinal
    Abdominal Pain
    • 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]
    • Charcot's triad: Fever Abdominal pain Jaundice Reynolds pentad: Fever Abdominal pain Jaundice Confusion Hypotension Charcot described the original triad in 1877 .[derangedphysiology.com]
    • pain, tenderness over the RUQ of the abdomen, and jaundice (charcot’s triad) • All signs and symptoms in only 53% to 88% of patients • Often, dark coloration of the urine resulting from bilirubinuria • Complications: 1.[encyclopedia.lubopitko-bg.com]
    • 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]
    • It tends to occur if the bile duct is already partially obstructed by gallstones.[1][2] Patients with this condition will manifest abdominal pain (particularly in the right upper quadrant of the abdomen), fever, rigors(uncontrollable shaking) and a feeling[gofundme.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]
    • 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]
    • […] all three: A , B and C Additionally, one may list supportive features which are not a part of the diagnostic criteria: Characteristic symptoms of biliary colic are the most common symptom In 72-93%, there is right hypochondrial and/or epigastric pain Nausea[derangedphysiology.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]
    • The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain.[sketchymedicine.com]
    Vomiting
    • 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]
    • , B and C Additionally, one may list supportive features which are not a part of the diagnostic criteria: Characteristic symptoms of biliary colic are the most common symptom In 72-93%, there is right hypochondrial and/or epigastric pain Nausea and vomiting[derangedphysiology.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]
    • The pain lasts longer than 6h and is usually associated with nausea/vomiting, fever and right upper quadrant pain.[sketchymedicine.com]
    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.[scribd.com]
    • […] infection/ RUQ pain/ fever if there will we low grade/ no jaundice since its not obstructing CBD/ murphys sign / first step is USG and if not conclusive HIDA scan choledocholithiasis: stone in CBD/ obstructive jaundice(jaundice is big thing here)/ RUQ or epigastric[usmleforum.com]
    • […] diagnosis: One item in all three: A , B and C Additionally, one may list supportive features which are not a part of the diagnostic criteria: Characteristic symptoms of biliary colic are the most common symptom In 72-93%, there is right hypochondrial and/or epigastric[derangedphysiology.com]
    Tenderness in the Right Upper Quadrant
    • On physical exam, he has tenderness in the right upper quadrant and is intermittently confused, often repeating himself.[medbullets.com]
    • A physical examination often reveals signs of jaundice as well as abdominal tenderness in the right upper quadrant area.[medicalsubstance.com]
    Clay-Colored Stool
    • Dark urine and clay-colored stools.[medlineplus.gov]
    • Other symptoms include fever, chills, clay-colored stools, vomiting and nausea, dark urine, and skin yellowing (jaundice).[diethealthclub.com]
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  • neurologic
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  • Entire body system
    Fever
    • 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]
    • . 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]
    • 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.[scribd.com]
    • The answer was ascending cholangitis based on the fact that she had a fever. 10% got it right.[forums.studentdoctor.net]
    • Most patients have fever, jaundice, and RUQ pain (Charcot's triad).[bestpractice.bmj.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]
    • • Males, for cholangitis secondary to malignant obstruction and HIV infection PREDOMINANT AGE: Seventh decade and older; unusual 50 years of age PEAK INCIDENCE: Seventh decade PHYSICAL FINDINGS & CLINICAL PRESENTATION • Usually acute onset of fever, chills[encyclopedia.lubopitko-bg.com]
    • Today he presents with fever and chills.[medbullets.com]
    • Systemic inflammation Fever and/or shaking chills Laboratory data: evidence of inflammatory response B.[derangedphysiology.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
    • It tends to occur if the bile duct is already partially obstructed by gallstones.[1][2] Patients with this condition will manifest abdominal pain (particularly in the right upper quadrant of the abdomen), fever, rigors(uncontrollable shaking) and a feeling[gofundme.com]
    • Ascending Cholangitis Signs and Symptoms AC patients may experience problems like: Abdominal pain Rigors Fever Malaise, or a feeling of uneasiness Jaundice may also be reported in some cases.[medicalsubstance.com]
    • Signs and symptoms [ edit ] A person with cholangitis may complain of abdominal pain (particularly in the right upper quadrant of the abdomen ), fever , rigors (uncontrollable shaking) and a feeling of uneasiness ( malaise ).[en.wikipedia.org]
    • Signs and symptoms A person with cholangitis may complain of abdominal pain (particularly in the right upper quadrant of the abdomen ), fever , rigors (uncontrollable shaking) and a feeling of uneasiness ( malaise ).[ipfs.io]
    • Presentation – rigors, fever, abdominal pain, jaundice Treatment It is a medical emergency.[almostadoctor.co.uk]
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  • Liver, Gall & Pancreas
    Jaundice
    • The bile flow is stanched and the patient will become jaundiced.[buckeyesurgeon.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]
    • Most patients have fever, jaundice, and RUQ pain (Charcot's triad).[bestpractice.bmj.com]
    • 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]
    • Illustration A represents scleral icterus, a sign of jaundice, and elevated bilirubin.[medbullets.com]
    Biliary Colic
    • That is more representative of biliary colic (even though biliary colic itself is often persistent) and maybe choledocholithiasis.[forums.studentdoctor.net]
    • Compare & contrast the S & Sx of RUQ P, fever/ WCC, & jaundice in biliary colic, acute cholecystitis, & cholangitis.[goconqr.com]
    • Run of the mill biliary colic can be managed as an outpatient.[buckeyesurgeon.com]
    • Evaluation and Treatment: Perform a thorough H&P: History of gallstones, biliary colic, or pancreatitis mechanical biliary obstruction History of back pain, weight loss, acholic stools pancreatic or biliary malignancy History of biliary reconstruction[emdocs.net]
    • colic are the most common symptom In 72-93%, there is right hypochondrial and/or epigastric pain Nausea and vomiting is the next most frequently seen feature Only about 30% have fever Rebound tenderness is only present in about 30-50% Rigidity and guarding[derangedphysiology.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).[emdocs.net]
    • Illustration A represents scleral icterus, a sign of jaundice, and elevated bilirubin.[medbullets.com]
    Hepatomegaly
    • Physical examination may reveal the following: Fever (90%), although elderly patients may have no fever RUQ tenderness (65%) Mild hepatomegaly Jaundice (60%) Mental status changes (10-20%) Sepsis Hypotension (30%) Tachycardia Peritonitis (uncommon, and[emedicine.medscape.com]
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  • 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].

    Pathology

    Biopsy
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  • Laboratory

    Serum
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  • Microbiology
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  • Imaging

    X-ray
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  • Angiography
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  • Treatment

    Prognosis

    Complications

    Obstructive Jaundice
    • : stone in cystic duct/this is inflammation and not infection/ RUQ pain/ fever if there will we low grade/ no jaundice since its not obstructing CBD/ murphys sign / first step is USG and if not conclusive HIDA scan choledocholithiasis: stone in CBD/ obstructive[usmleforum.com]
    • Most patients present with obstructive jaundice caused by compression of the bile duct in the head of the pancreas.[medbullets.com]
    • (deim-i study). ( 23687602 ) Mok S.R....Judge T.A. 2012 6 Endoscopic management of afferent loop syndrome after a pylorus preserving pancreatoduodenecotomy presenting with obstructive jaundice and ascending cholangitis. ( 22741115 ) Kim J.K....Bang S.[malacards.org]
    • Parasitic infestation can cause obstructive jaundice with intrahepatic ductal inflammation, proximal stasis, stone formation, and cholangitis.[merckmanuals.com]
    • Obstructive jaundice promotes bacterial translocation in human .[nature.com]
    Fever
    • 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]
    • . 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]
    • 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.[scribd.com]
    • The answer was ascending cholangitis based on the fact that she had a fever. 10% got it right.[forums.studentdoctor.net]
    • Most patients have fever, jaundice, and RUQ pain (Charcot's triad).[bestpractice.bmj.com]
    Acute Pancreatitis
    • Pancreatitis Chronic Pancreatits Pancreatic Pseudocyst Acute Bowel Disorders Diarrhea Lower GI Bleed Volvulus Appendicitis Ischemic Colitis Mesenteric Ischemia Small Bowel Obstruction Large Bowel Obstruction Ogilvie Syndrome Paralytic / Adynamic Ileus[medbullets.com]
    • The 2 major complications are 1) Cholangitis and 2) Acute pancreatitis.[sketchymedicine.com]
    • pancreatitis K85.00 …… without necrosis or infection Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.[icd10data.com]
    • Over ten years, 15–26% will suffer one or more episodes of biliary colic (abdominal pain due to the passage of gallstones through the bile duct into the digestive tract), and 2–3% will develop complications of obstruction: acute pancreatitis , cholecystitis[en.wikipedia.org]
    • Over ten years, 15–26% will suffer one or more episodes of biliary colic (abdominal pain due to the passage of gallstones through the bile duct into the digestive tract), and 2–3% will develop complications of obstruction: acute pancreatitis , cholecystitis[ipfs.io]
    Shock
    • If untreated, sepsis with shock, vascular collapse, multiorgan failure, and potentially death can occur.[blood-test.biz]
    • Reynolds’ pentad includes mental confusion and septic shock – two more symptoms apart from the three common with Charcot’s triad.[medicalsubstance.com]
    • Bacteremia (53%) and septic shock 2.[encyclopedia.lubopitko-bg.com]
    • If untreated, sepsis with shock, vascular collapse, multi-organ failure, and potentially death can occur.[bestpractice.bmj.com]
    • […] 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: infection / deadly RUQ pain jaundice fever(very ill patient) septic shock[usmleforum.com]
    Liver Abscess
    • […] wall thickening with hyperenhancement Intraductal purulent bile or pus: High density on CT, intermediate to low signal on T1 and T2WI MR Heterogeneous liver enhancement, which can be wedge-shaped, peribiliary, patchy, or diffuse Can be associated with liver[clinicalgate.com]
    • We report a case where ascending cholangitis was associated with pyogenic liver abscess formation and a gastric fistula.[journals.lww.com]
    • View Article Google Scholar Nakarai T, Morita K, Nojiri Y, Nei J, Kawamori Y: Liver abscess due to lactococcus lactis cremoris .[jmedicalcasereports.biomedcentral.com]
    • Obtain blood cultures Differential Pancreatic cancer, cholangiocarcinoma, carcinoma of the bile ducts, metastatic carcinoma, primary biliary cirrhosis, cholecystitis, pancreatitis, sepsis, liver abscess.[medbullets.com]
    • DIFFERENTIALS • Biliary Leak • Cholecystitis • Pancreatitis • Liver Abscess • Infected Choledochal cyst • Recurrent Pyogenic cholangitis • Mirizzi syndrome • RLL pneumonia • Biliary Tree Malignancy 15.[slideshare.net]
    Jaundice
    • The bile flow is stanched and the patient will become jaundiced.[buckeyesurgeon.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]
    • Most patients have fever, jaundice, and RUQ pain (Charcot's triad).[bestpractice.bmj.com]
    • 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]
    • Illustration A represents scleral icterus, a sign of jaundice, and elevated bilirubin.[medbullets.com]
    Acute Cholecystitis
    • S & Sx of acute cholecystitis.[goconqr.com]
    • acute cholecystitis: stone in cystic duct/this is inflammation and not infection/ RUQ pain/ fever if there will we low grade/ no jaundice since its not obstructing CBD/ murphys sign / first step is USG and if not conclusive HIDA scan choledocholithiasis[usmleforum.com]
    • Even patients with acute cholecystitis can be cooled down for 24-48 hours with fluids and IV antibiotics prior to definitive surgery.[buckeyesurgeon.com]
    • Cholecystitis Choledocholithiasis Gallstone Ileus Ascending Cholangitis Primary Sclerosing Cholangitis Primary Biliary Cirrhosis Secondary Billiary Cirrhosis Pancreatic Disorders Acute Pancreatitis Chronic Pancreatits Pancreatic Pseudocyst Acute Bowel[medbullets.com]
    • A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis .[coreem.net]
    Septicemia
    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]
    • DEFINITIVE TREATMENT OF CAUSE • Cholecystectomy • Stent • Urgent decompression- - Persistent abdo pain - Hypotension despite adequate resus - Fever 39.0*C - Confusion/ delerium 19.[slideshare.net]
    • A minority of patients present in shock with hypotension and altered mentation.[ncbi.nlm.nih.gov]
    • Question 9 from the second paper of 2016 presented the candidates with a scenario of an elderly woman with jaundice, confusion, hypotension, fever and abdominal pain.[derangedphysiology.com]
    • In addition to pain/fever/ jaundice, hypotension and mental status changes are seen in this more severe variety of ascending cholangitis.[buckeyesurgeon.com]
    Bacterial Endocarditis
    Pelvic Inflammatory Disease
    Cholestasis
    • Institute of Diabetes and Digestive and Kidney Diseases ALP - blood test (Medical Encyclopedia) Bile duct obstruction (Medical Encyclopedia) Biliary atresia (Medical Encyclopedia) Biliary stricture (Medical Encyclopedia) Cholangitis (Medical Encyclopedia) Cholestasis[icdlist.com]
    • Acute cholangiolitis is associated not only with bile duct obstruction but may also be seen in any liver disease related to prominent cholestasis that also involves the periportal zones.[humpath.com]
    • Abdominal pain (most commonly RUQ) High fever Jaundice (less common) Reynolds pentad : Charcot cholangitis triad hypotension and mental status changes seen in severe cholangitis Possible septic shock References: [3] Diagnostics Leukocytosis , CRP Signs of cholestasis[amboss.com]
    • It is characterized by fibrosis and hardening of the intrahepatic and extrahepatic biliary ductal systems leading to bile duct strictures, cholestasis, and eventual biliary cirrhosis.[icd10data.com]
    Viral Hepatitis
    • […] abscess Pylephlebitic hepatic abscess Type 1 Excludes amebic liver abscess ( A06.4 ) cholangitis without liver abscess ( K83.0 ) pylephlebitis without liver abscess ( K75.1 ) Type 2 Excludes acute or subacute hepatitis NOS ( B17.9 ) acute or subacute non-viral[icd10data.com]
    • Hepatitis - eg, viral hepatitis , drug-induced hepatitis .[patient.info]
    Septic Shock
    • Bacteremia (53%) and septic shock 2.[encyclopedia.lubopitko-bg.com]
    • shock and altered mental status can also be seen hyperbilirubinemia/ leucocytosis can lead to hepatic abscess which has high mortality hope this helps[usmleforum.com]
    • A 79 year old man with a history of quadriplegia presented to an outside hospital in septic shock.[swjpcc.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]
    • shock or developing SIRS/sepsis after 12-24 hours of antibiotics emergent decompression Patients clinically improving s/p antibiotics and fluid resuscitation decompression scheduled prior to hospital discharge 2 Pearls: Severe abdominal pain is uncommon[emdocs.net]
    Primary Biliary Cirrhosis
    • Obtain blood cultures Differential Pancreatic cancer, cholangiocarcinoma, carcinoma of the bile ducts, metastatic carcinoma, primary biliary cirrhosis, cholecystitis, pancreatitis, sepsis, liver abscess.[medbullets.com]
    • biliary cirrhosis (Medical Encyclopedia) [ Read More ][icdlist.com]
    • biliary cirrhosis 2016 2017 2018 Billable/Specific Code Applicable To Chronic nonsuppurative destructive cholangitis K74.3 ) The following code(s) above K83.0 contain annotation back-references Annotation Back-References In this context, annotation back-references[icd10data.com]
    Secondary Sclerosing Cholangitis
    • The third type of cholangitis is secondary sclerosing cholangitis, and this is caused due to some other reasons.[diethealthclub.com]
    Perforated Peptic Ulcer
    Leukocytosis
    • There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated.[ncbi.nlm.nih.gov]
    • The idea was that it presented exactly like stones (since that can be an aetiology of AC), but that one needs to be aware of the fever and/or leukocytosis.[forums.studentdoctor.net]
    • […] biliary malignancy History of biliary reconstruction or endoscopic biliary duct manipulation stricture/indwelling stent occlusion Evaluation: Labs: LFTs: conjugated hyperbilirubinemia, transaminitis, elevated alkaline phosphatase, elevated GGT CBC: leukocytosis[emdocs.net]
    • Diagnostic gold standard is: ERCP (endoscopic retrograde panreaticoduodenoscopy) PTCA (percutaneous transhepatic cholangiogram) Labs: neutrophillic leukocytosis increased bilirubin increased alkaline phosphatase and glutamyltransferase.[medbullets.com]
    • Biochemical analyses demonstrated a leukocytosis and neutrophilia; haemoglobin (Hb) 11.9 g/dL, white blood cell count (WCC) 13.9 10 9 /L, neutrophils 11.4 10 9 /L.[jmedicalcasereports.biomedcentral.com]

    Etiology

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    References

    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.
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