acute cholangitis

  • pathogenesis:
    • common bile duct ascending bacterial infection
    • result of choledocholithiasis: disruption of normal bile flow, bacteria ascend biliary tract from duodenum
  • cause:
    • E. coli (25 to 50%)
    • Klebsiella pneumonia (15 to 20%)
    • Enterobacter species (5 to 10%)
    • Enterococcus species (10 to 20%)
    • Bacteroides and Clostridia (anaerobes, usually part of a mixed infection)
  • sx:
    • charcot triad: RUQ, fever, jaundice
    • reynolds pentad: hypotension, AMS. Indicative of suppurative cholangitis due to septic shock
  • labs:
    • leukocytosis
    • cholestatic liver function test
  • imaging
    • US RUQ: biliary duct dilation without gas in biliary tree
    • emphysematous cholecystitis: gas in biliary tree
  • treatment
    • IVF, blood cultures, abx
      • zosyn or cipro with flagyl
    • biliary drainage with ERCP in 24-48 hours
    • if not possible, percutaneous cholangiography with biliary tube placement
    • Elective cholecystectomy in 2 weeks to prevent future episodes