Ascending Cholangitis

Definition

• Life-threatening complication of gallstones

• Usually caused by impacted stone in the bile duct that predisposes to bacterial infection --> septicemia

• Most common organisms:

  • E coli

  • Klebsiella

  • Pseudomonas

  • Enterococcus

Clinical Features

• Typical symptoms (Charcot's Triad):

  • (1) Fever

  • (2) Jaundice

  • (3) RUQ pain

• Less frequent symptoms (10-20%) (Reynaud's pentad)

  • (4) Altered mental status

  • (5) Hypotension

  • These are associated with higher mortality and morbidity than Charcot's triad alone

Diagnosis

• Labs

  • Leukocytosis with left shift

  • Hyperbilirubinemia

  • Elevated ALP and AST/ALT

• Imaging

  • CT > US accuracy

    • These are not good for exclusion of BD stone

  • ERCP for diagnosis and therapy

  • MRCP

Treatment

• Broad spectrum antibiotics

  • Most cases: single IV abx like cefoxitin

  • Severe cases: use similar abx like acute cholecystitis

  • Adjust according to blood cultures

• Biliary decompression

  • Urgency depends on response to supportive therapy and abx

  • Modality:

    • Hemodynamically stable: ERCP

    • Hemodynamically unstable: percutaneous cholecystostomy tube

• Cholecystectomy to prevent further gallstone formation or migration