EXPLAINING OF ASCENDING CHOLANGITIS

Jan 18, 2014 tamplets: 0 comment
EXPLAINING OF ASCENDING CHOLANGITIS

Definition

 Acute cholangnitis: is an ascending bacterial infection of common bile duct in association with partial or complete obstruction of the bile ducts or acute inflammation of common bile duct
When associated with  kidney (renal) failure,  heart (cardiac) impairment,  liver (hepatic) abscesses, and malignancies the morbidity and morality rates may be high
 
is one of the two main complications of common bile duct (choledochal) stones, the other gallstone pancreatitis
. Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous bile flow and by the pres­ence of antibacterial substances in bile such as immunoglobulin
Mechanical hindrance to bile flow facilitates bacterial contamination
Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction
 Biliary bacte­rial contamination alone does not lead to clinical cholangitis; the combination of both significant bacterial contamination and biliary obstruction is required for its development
  • Gallstones are the most common cause of obstruction in cholangitis
  • benign and malignant strictures  of common bile duct
  •  parasites infestation of common bile duct
  • instrumentation of the ducts and indwelling stents
  •  partially obstructed biliary-enteric anastomosis 
 Causative organisms

 The most common organisms cultured from bile in patients with cholangitis include
  • Escherichia coli
  • Klebsiella
  • pneumoniae
  • Streptococcus faecalis
  • Bacteroides fragilis
Clinical Presentation symptoms and signs
Cholangitis may be take one of the following pictures
  •   Mild cholangitis
  •  Intermittent
  •  Self-limited disease
  •   Fulminant life-threatening septicemia
The patient with gallstone­ induced cholangitis is typically older and female
The most common presentation
  • Fever raised body temperature
  •  Epigastric or right upper quadrant pain
  • Jaundice yellowish discolouration of the sclera of the eye
  • Charcot's triad
These classic symptoms well known as Charcot's triad,traid mean three as (fever pain and jaundice) are present in about two thirds of patients
  •  Reynolds pen­tad
The illness may progress rapidly with septicemia and disorientation, known as Reynolds pen­tad means five as  (e.g., fever , jaundice, right upper quadrant pain, septic shock, and mental status changes
  •   Atypical presentation with little if any fever, jaundice or pain
   This occurs most com­monly in the elderly, who may have unremarkable symptoms until they collapse with septicemia
  •  Patients with indwelling stents rarely become jaundiced. on abdominal examination, the findings are in­ distinguishable from those of acute cholecystitis
 
Diagnosis and investigations
Laboratory
  • Full blood count leukocytosis
  • Liver function test hyperbiliru­binemia, and elevation of alkaline phosphatase and transamioases enzymes
  • Urine analysis urobilinogen or bilirubin may present in jaundice
  when these present,  they support the clinical diagnosis of cholangitis
Radiological studies
Ultrasonography
 Abdominal ultrasound is helpful if the patient has not been diagnosed previously with gallstones
 
  It showing the pres­ence of gallbladder stones and dilated common bile ducts and possibly detect the site of obstruction
 
 The definitive diagnostic test is ERCP. in cases in which ERCP is not available, PTC is Indicated
Both ERCP and PTC will show
  • Level and the causes of the obstruction
  • Allow culture of the bile
  •  Allow the removal of stones if present
  • Drainage the bile ducts With drainage catheters or stents
Will show pancreatic and periampullary masses if present addition to the ductal dilatation

Treatment

  The initial treatment intravenous antibiotics and fluid resuscitation
These patients may re­quire intensive care unit monitoring and vasopressor support, Most patients will respond to these measures
 The obstructed bile duct must be drained as soon as the patient has been stabilized
 Some patients  may not respond to antibiotics and fluid resuscitation, and need for an emergency biliary decompression
Biliary decompression either by
  • Endoscopically by the percutaneous transhepatic route by ERCP or PCT
  •  Surgically by exploration of common bile duct with T tube insertion for bile drainage 
This depend on based on the level and the nature of the biliary obstruction as follow
   
Patients with stones in common bile duct (choledocholithiasis) or periampullary ma­lignancies are best approached endoscopically by
 ERCP with sphincterotomy and stone removal, or by placement of an endoscopic biliary stent
 In patients in whom the obstruction is more proximal or perihilar, or when a stricture in a biliary-enteric anastomosis is the cause or the endoscopic route has failed, percutaneous transhepatic drainage (PTC) is used
Where neither ERCP nor PTC is possible, an emergent opera­tion and decompression of the common bile duct with a T tube may be necessary and life-saving
Definitive operative therapy should be deferred until the cholangitis has been treated and the proper di­agnosis established

Patients with indwelling stents and cholangitis usually require repeated imaging and exchange of the stent over a guidewire

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