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)
• - Know your pathology. major bugs that cause this are:
  • - Enteric Gram negatives - E coli (20-25%), Klebsiella (15-20%),
  • Enterobacter (5-10%)
  • - GP - Enterococcus (10-20%)
  • - Anaerobes - Bacterodes, clostridia
  • So your choice of antibiotic should target these organisms. Forpatients that appear less ill, treating with just a floroquinolone hasbeen proven effective (Cipro) as you are targeting the gram negatives. The more ill they are, the more you add coverage, i.e. adding
    metronidazole for anaerobes or broadening to zosyn/unasyn to coverEnterococcus. In general, from least to heavy you could use:cipro,cipro+/-flagyl, ceftriaxone +/- flagyl, unasyn, zosyn,
    carbepenem.
  • Normal duration is 7-10 days, although some studies have shown good outcomes with 3 days if adequate drainage was done.
  • Source control - ERCP is the mainstay of source control, however otheroptions are IR and surgery. ERCP has a much better survival andcomplication rate than surgey (50% less complications, 70% less mortality). Learn more about ERCP complications.
• 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, 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 

(Troy Leo MD, 6/10/11)

(Victoria Kelly MD, 8/6/10)