Dr. Sinkoff presented a male who had presented with fever, abdominal pain, diarrhea, and vomiting who was found to have acute cholangitis.
What is acute cholangitis?
Acute cholangitis is a bacterial infection that develops in the biliary tree secondary to obstruction. Bacteria from the duodenum begin to invade the ducts when obstruction occurs (secondary to stones, strictures, or malignancy), resulting in severe infection. The most common bacterial causes are E. coli, Klebsiella, Enterobacter, Enterococcus, Bacteroides, and Clostridia.
How do patients with acute cholangitis present?
Classically, patients present with Charcot's triad of jaundice, RUQ pain, and fevers, although this is only seen in about 1/2 of patients with acute cholangitis. If suppurative cholangitis develops, patients get very sick and can develop Reynold's pentad (Charcot's triad + hypotension + AMS).
How is acute cholangitis diagnosed?
History and physical are essential to the diagnosis. LFTs should be obtained in patients with suspected cholangitis, because they are often elevated. Imaging is then often performed.
If patient is not severely ill, abdominal ultrasound is often pursued first. Abdominal ultrasound has a high specificity for bile duct dilation and bile duct stones (94-100%), but the sensitivity for the detection of dilated bile ducts and biliary obstruction ranges from 38 to 91%.
If patients have abnormal LFTs and/or jaundice in the setting of abdominal pain and fever, ERCP is often just performed right away.
In addition to a GI consult for ERCP, what do I do when I am admitting someone with suspected acute cholangitis?
If you suspect acute cholangitis, in addition to careful monitoring, patients require immediate broad-spectrum antimicrobial therapy (i.e. intravenous antibiotic such as a β-lactam/β-lactamase inhibitor or a third-generation cephalosporin plus metronidazole). However, if they don't improve rapidly, urgent endoscopic stone removal is required. Those who improve with antibiotics can undergo elective stone removal, often on an outpatient basis.
References:
1. MKSAP 17
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