Choleangitis - Dr. Ju's Blog

### 날짜 : 2024-02-13 20:32 ### 주제 : #medicine #간담췌 #internalmedicine ---- Cholangitis is a serious condition characterized by inflammation of the bile ducts, which are the tubes that carry bile from the liver to the gallbladder and small intestine. This inflammation is typically caused by a bacterial infection, obstruction of the bile ducts, or a combination of both. Here's a breakdown of important points to study about cholangitis: 1. **Etiology**: - Bacterial infection: Cholangitis commonly arises from bacterial overgrowth in the bile ducts, often due to obstruction caused by gallstones or strictures. - Obstruction: Anything that blocks the bile ducts, such as gallstones, tumors, or strictures, can lead to bile stasis and subsequent infection. - Risk factors: These include gallstones, bile duct strictures, bile duct tumors, biliary stenting, and previous biliary surgery. 2. **Pathophysiology**: - Obstruction leads to stasis of bile, providing a medium for bacterial proliferation. - Bacteria ascend the biliary tree, leading to infection and inflammation. - Inflammation can result in damage to the bile duct epithelium, further compromising biliary drainage. 3. **Clinical Presentation**: - Charcot's triad: Fever, right upper quadrant pain, and jaundice. - Reynolds' pentad (in severe cases): Charcot's triad plus altered mental status and hypotension, indicating systemic inflammatory response syndrome (SIRS) and sepsis. - Other symptoms may include chills, nausea, vomiting, and malaise. 4. **Diagnostic Evaluation**: - Blood tests: Elevated liver enzymes (AST, ALT, ALP), bilirubin, and white blood cell count (indicating inflammation and infection). - Imaging: Ultrasonography, CT scan, or MRI can reveal biliary dilatation, stones, or other obstructive lesions. - Endoscopic retrograde cholangiopancreatography (ERCP): Both diagnostic and therapeutic; allows visualization and potential clearance of bile duct obstruction. 5. **Management**: - Antibiotics: Broad-spectrum antibiotics (e.g., piperacillin-tazobactam, ceftriaxone, metronidazole) to cover common pathogens, typically started empirically pending culture results. - Biliary decompression: ERCP with sphincterotomy and stent placement to relieve obstruction. - Surgical intervention: In cases of severe obstruction or in those where endoscopic management fails, surgical drainage may be necessary. - Supportive care: Fluid resuscitation, electrolyte management, and monitoring for signs of sepsis. 6. **Complications**: - Sepsis: Can progress rapidly, especially in cases of complete biliary obstruction. - Liver abscess: Pus collection within the liver parenchyma due to bacterial spread from the bile ducts. - Acute kidney injury: Due to sepsis-induced renal hypoperfusion. 7. **Prognosis**: - Prompt diagnosis and appropriate management are crucial for a favorable outcome. - Mortality rates can be high, particularly in cases of severe cholangitis associated with sepsis. Remember to review relevant anatomy, physiology, and microbiology concepts to fully understand cholangitis and its management. Additionally, stay updated on current guidelines and recommendations in the field of gastroenterology and hepatology. --- **Case Example:** **Patient Presentation:** A 65-year-old male presents to the emergency department with a two-day history of fever, right upper quadrant abdominal pain, and jaundice. He reports experiencing chills and nausea but denies vomiting. His past medical history is significant for gallstones diagnosed two years ago, for which he was advised cholecystectomy but did not undergo the procedure. On examination, he appears jaundiced and is febrile with a temperature of 38.8°C (101.8°F). Abdominal examination reveals tenderness in the right upper quadrant. **Clinical Assessment:** 1. **Charcot's Triad:** Fever, right upper quadrant pain, and jaundice. 2. **Initial Differential Diagnosis:** - Acute cholecystitis - Acute hepatitis - Pancreatitis - Biliary obstruction - Acute appendicitis (less likely given the jaundice and right upper quadrant tenderness) **Diagnostic Workup:** 1. **Laboratory Tests:** - Complete blood count: Elevated white blood cell count (indicating infection). - Liver function tests: Elevated bilirubin, alkaline phosphatase (ALP), and transaminases (indicating biliary obstruction and hepatocellular injury). - Serum amylase and lipase: To rule out pancreatitis. 2. **Imaging:** - Ultrasonography: Shows dilated common bile duct (CBD) with evidence of choledocholithiasis (gallstones in the bile duct). - Computed tomography (CT) scan: May be performed to further evaluate the biliary tree and rule out other causes of abdominal pain and jaundice. 3. **Endoscopic Retrograde Cholangiopancreatography (ERCP):** - Urgently performed for both diagnostic confirmation and therapeutic intervention. - Reveals evidence of bile duct obstruction by multiple stones. - Sphincterotomy and stone extraction are performed during the procedure. **Treatment:** 1. **Antibiotic Therapy:** - Initiated empirically with intravenous piperacillin-tazobactam to cover gram-negative and anaerobic organisms commonly associated with biliary infections. 2. **Biliary Decompression:** - ERCP with sphincterotomy and stone extraction is performed to relieve biliary obstruction and improve bile flow. - A plastic stent is placed in the CBD to maintain drainage and prevent recurrence of obstruction. 3. **Supportive Care:** - Intravenous fluids and electrolyte replacement are administered to maintain hydration and correct any electrolyte imbalances. - Analgesics are given for pain relief. - Close monitoring of vital signs, fluid status, and response to treatment. **Follow-up:** The patient shows significant clinical improvement following biliary decompression and antibiotic therapy. He undergoes elective cholecystectomy once stabilized to prevent future episodes of cholangitis. This case highlights the typical presentation, diagnostic evaluation, and management approach for a patient with acute cholangitis secondary to choledocholithiasis. Early recognition and prompt intervention are essential to prevent complications and improve patient outcomes.