Biliary Tract: Acute Cholangitis

Acute Cholangitis

Definition

  • Inflammation of CBD

Causes

Infection

  • Bile Typically Sterile Due to:
    • Continuous Flow
    • IgA Secretion
    • Bacteriostatic Bile Salts
  • Sources of Infection:
    • Translocation from Portal Vein Due to Increased Bile Duct Permeability (Most Common)
    • Ascending Cholangitis – Ascends from Duodenum
  • Stones or Stents Will Act as a Nidus for Infection
  • Most Common Organisms: E. coli #1, Klebsiella, Pseudomonas, Enterobacter & Enterococcus

Presentation

  • Charcot’s Triad: RUQ Pain, Fever & Jaundice
  • Reynold’s Pentad: Triad + Hypotension & Altered Mental Status
  • Labs: Leukocytosis, Hyperbilirubinemia & Elevated LFT’s

Diagnosis

  • Approach:
    • If Uncertain of Dx: US, CT or MRCP
    • If Certain of Dx: Proceed with ERCP
  • Diagnostic Criteria: (Based on TG18)
    • Categories:
      • A: Systemic Inflammation
        • A-1: Fever or Shaking Chills
        • A-2: Lab Evidence of Inflammatory Response (WBC < 4,000, WBC > 10,000 or CRP ≥ 1 mg/dL)
      • B: Cholestasis
        • B-1: Jaundice (Bilirubin ≥ 2 mg/dL)
        • B-2: Lab Evidence of Abnormal LFTs (Alk-Phos, AST, ALT or GGT > 1.5x the Upper Limit of Normal)
      • C: Imaging
        • C-1: Biliary Dilation
        • C-2: Etiology Seen on Imaging (Stricture, Stone or Stent)
    • Diagnosis:
      • Suspected Diagnosis: One in A and One in B or C
      • Definite Diagnosis: One of Each A, B and C

Grading – Tokyo Guidelines 2018 (TG18)

  • Grade I (Mild) – Does Not Meet Criteria for Grade II-III
  • Grade II (Moderate) – Associated with ≥ 2 Of:
    • Abnormal WBC (< 4,000 or > 12,000)
    • High Fever (≥ 39 C)
    • Age (≥ 75 Years)
    • Hyperbilirubinemia (Total Bili ≥ 5 mg/dL)
    • Hypoalbuminemia (< 0.7x Upper Limit of Normal)
  • Grade III (Severe) – Dysfunction of ≥ One Of:
    • Cardiovascular (Vasopressor Support)
    • Neurologic
    • Respiratory
    • Renal (Cr > 2.0 mg/dL or Oliguria)
    • Hepatic (INR > 1.5)
    • Hematologic (Plt < 100,000)

Treatment

  • Tx: IVF, Empiric ABX & ERCP
    • If from Choledocholithiasis: Elective Cholecystectomy (Same Hospitalization)
    • If from Infected Foreign Object:
      • Stent or PTC (Percutaneous Transhepatic Cholangiography) Tube – Exchange
      • T-Tube – Open to Drain