Cholangitis

1. Clinical dx of cholangitis:

Charcot's triad: fever, RUQ pain and jaundice
Reynold's pentad: as above + hypotension and AMS
a retrospective review of 108 pts with a diagnosis of acute cholangitis found that 42% of pts had Charcot's triad and 3% had Renolyd's pentad. This study found that predictors of poor outcome included TBili>10 and WBC >20K (see link to article): http://sfx.stanford.edu.laneproxy.stanford.edu/local?sid=Entrez:PubMed&id=pmid:17983054
choledocholithiasis is the most common cause of cholangitis it western countries; malignant biliary obstructions rarely cause cholangitis unless there was a prior ERCP or stent placement. Parasitic infections (ascaris lumbicoides and clonorchis sinensis) are more common causes of cholangitis in the developing world
several scoring systems exist to categorize the severity of cholangitis, including the Tokyo guidelines in 2006, which really is only pertient for prognostic reasons and determining the urgency of ERCP
abd US is the preferred initial imaging study as it highly sensitive and specific for examining the GB and biliary dilation, ERCP (or EUS in certain settings) is the preferred definitive study, as it can also be therapeutic

2. Managment of cholangitis:

initial managment includes antibiotics and aggressive IVF
abx should be directed at gram negative enteric organisms (ie. E.Coli, Klebsiella), as well as gram positives (ie. enterococcus) and anaerobes (bacteriodes and clostridium)
initial abx regimens include a betalactamase PCN + anaerobic coverage, ie. ampicillin/sulbactam, pipercillin/tazobactam, 3rd gen cephalosporin or flouroquinolone + metronidazole; complicated patients with a h/o of prior instrumentation, malignancy or resistant infections may require broader coverage for ESBL etc. (ie. carbapenem)
biliary decompression in the next cornerstone in managment and is generally done by ERCP; timing is dependent on the severity of infection and initial response to abx, but generally should be done within 24-48 hrs
endoscopic treatment with permanent or temporary stenting +/- sphincterotomy depends on the clinical scenario (see review article on managment), but cholecystectomy is generally recommeneded when choledocholithiasis is the cause of obstruction (after acute infection is resolved)

3. Mirizzi's syndrome:

a rare compication of prolonged cholelithiasis, characterized by narrowing of the common hepatic duct due to mechanical compression and/or inflammation from a biliary stone in the neck of the gallbladder or cystic duct
see a review of Mirizzi's syndrome: http://sfx.stanford.edu.laneproxy.stanford.edu/local?sid=Entrez:PubMed&id=pmid:11206888

(Victoria Kelly MD, 8/6/10)