Topic 42 of 74 in the MU Sofia syllabus for Surgery (Medicine, Year 5). The free AceMed note covers it in 2 sections, about 272 words (2 min of reading), with 15 flashcards.
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TOPIC 42
Cholangitis
Cholangitis
DEFINITION & AETIOLOGY
Acute cholangitis is infection of the biliary tree in the presence of biliary obstruction, most commonly due to common bile duct stones.
Other causes include benign strictures, malignant obstruction (pancreatic, ampullary or cholangiocarcinoma), biliary stents and postoperative narrowing.
Obstruction raises ductal pressure, promotes bacterial overgrowth and allows bacteria/endotoxin to enter the bloodstream, causing sepsis.
MICROBIOLOGY & CLINICAL FEATURES
Common organisms are enteric Gram-negative bacteria such as E. coli and Klebsiella, Enterococcus species and anaerobes in selected cases.
Charcot triad: fever/rigors, RUQ pain and jaundice. Reynolds pentad adds hypotension and altered mental status, indicating severe disease.
Older or immunocompromised patients may lack the full triad. Look for sepsis, confusion, oliguria and organ dysfunction.
INVESTIGATIONS
Blood tests: full blood count, CRP, liver profile (often cholestatic pattern), bilirubin, renal function, coagulation, lactate and blood cultures before antibiotics if this does not delay treatment.
Ultrasound assesses duct dilatation and gallstones. MRCP or EUS defines obstruction in stable patients. CT evaluates malignancy or complications.
Diagnosis is based on systemic inflammation, cholestasis and imaging evidence of biliary obstruction/inflammation, interpreted together.
MANAGEMENT
Acute cholangitis is an emergency. Resuscitate, monitor, obtain cultures and start broad-spectrum IV antibiotics covering enteric Gram-negative organisms and appropriate additional pathogens according to local guidance.
Urgent biliary decompression is essential in severe disease or failure to improve. ERCP with sphincterotomy, stone extraction and/or stenting is preferred when feasible.
Percutaneous transhepatic biliary drainage or surgical drainage is considered when ERCP is not possible or fails.
After stabilisation, treat the cause: cholecystectomy for gallstone disease, or appropriate management of strictures and malignancy.
Complications include septic shock, hepatic abscess, acute kidney injury, coagulopathy and multi-organ failure.
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