Inpatient / infectious disease
Cholangitis
# Acute Cholangitis
Checklist
-- ABCs: evidence of sepsis or shock requiring pressors and ICU care
-- Chart Check: known malignancy, gallstones, previous ERCP, stents, infections
-- Can't Miss: septic shock, new malignancy
-- Admission Orders: CBC, CMP, coags, lactate, BCx, RUQUS
-- Initial Treatment to Consider: fluids, abx, GI consult for ERCP
Assessment:
-- History: *** h/o stones, stents, MDROs, cancer, HIV
-- Clinical/Exam: *** Charcot Triad: RUQ pain, fever, jaundice; Reynold’s Pentad: + shock and AMS
-- Data: *** WBC, Tbili, AST/ALT, RUQUS
-- Etiology/DDx: *** Etiology: stone, cancer, PSC; DDx: cholecystitis, hepatitis, pancreatitis
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Imaging: *** (RUQUS → CTAP → MRI)
-- Monitoring: *** (CBC, LFTs)
Treatment
-- Abx: *** for 7 days (zosyn vs CTX/flagyl vs meropenem)
-- IVF: ***, s/p ***
-- Consult: *** GI for urgent ERCP within 24-48 hours if no improvement with abx; surgery for perc chole
-- to discuss cholecystectomy if the acute infection was due to gallstones
PDF coming soon!
If You Remember Nothing Else
Cholangitis is an ascending biliary infection due to obstruction at the level of the common bile duct. The obstruction can be gallstones, strictures, or malignancy (pancreatobiliary cancers commonly). Get antibiotics started immediately and recognize that unless you achieve source control via relief of obstruction (commonly via ERCP), the patient will not improve.
Clinical Pearls
- Cholangitis is an ascending biliary infection due to obstruction at the level of the common bile duct
- Those with palliative stenting for malignant obstruction are at increased risk
- Post ERCP complications include pancreatitis and hematogenous seeding of bacteria
- RUQUS > CT for detecting the presence of stones in the gallbladder; for choledocholithiasis will see CBD dilation >7mm but likely not the stone
- Acalculous cholecystitis can be seen in acute illness due to stasis/ischemia - will see GB thickening, pericholecystic fluid, sonographic Murphy’s
Trials and Literature
Other Resources
