Acute cholangitis
- An ascending bacterial infection associated with partial or complete obstruction of the bile duct
- Most commonly as a result of obstruction of the bile duct by a stone (choledocholithiasis)
Etiology
- Gallstone
- Neoplasm
- Strictures
- Indwelling stents
- Parasites
Pathology
- Normally bile is kept sterile, however mechanical obstruction to bile flow facilitates ascending bacterial contamination from the bowel
- Most common pathogens – Klebsiella, E.coli, Enterbacter, Bacteroides
Clinical features
- Charcot’s triad – RUQ pain, fever, jaundice
- Reynold’s pentad – RUQ pain, fever, jaundice, shock, altered mental status
Investigations
- US – dilation of biliary tree and presence of stone/obstruction
- Cholangiography via ERCP
- Leukocytosis, hyperbilirubinemia, ↑ALP
Treatment
- Hydration and broad spectrum IV antibiotics started immediately
- Biliary decompression – via ERCP and sphincterotomy
- Treat primary cause of obstruction
Primary sclerosing cholangitis
- Idiopathic, likely autoimmune, process affecting the intrahepatic and extrahepatic biliary tree
Etiology – exact cause unknown
- Associated with other diseases
- Ulcerative colitis
- Fibrosing diseases – Riedel thyroiditis, retroperitoneal fibrosis, mediastinal fibrosis
- Patients have an increased risk of developing cholangiocarcinoma
Pathology
- Inflammation of the bile duct with consequent stricturing and sclerosis
- Results in obstruction of bile flow
- Progressive chronic cholangitis, advances at an unpredictable rate to biliary cirrhosis, and eventually death
Clinical features
- Most patients are asymptomatic
- Fatigue, pruritis, jaundice
- Hepatosplenomegaly
- Abdominal pain
Investigations
- ERCP – beaded appearance of biliary tree (alternating stricture and dilation)
- LFTs
- Liver biopsy
Treatment
- Stenting
- Corticosteroids and immunosuppressants
- Ursodeoxycholic acid
- Liver transplant – definitive treatment
Biliary strictures
Etiology
- Post operative – after cholecystectomy or biliary surgery
- Inflammatory – CBD stones, acute cholangitis, gallbladder stones (Mirizzi syndrome), sclerosing cholangitis
- Malignant – cholangiocarcinoma
- Traumatic
Classification – Bismuth Classification
- I – stricture >2m distal to the hepatic confluence
- II – <2cm distal to the hepatic confluence
- III – at the level of the hepatic confluence
- IV – involves the right or left hepatic duct
- V – extends into the left or right hepatic branch ducts
Clinical features
- Obstructive jaundice
- Abdominal pain
- Episodes of recurrent episodes of cholangitis
- Profuse persistent bile leak
Investigations
- US abdomen
- ERCP/MRCP
- LFTs
Treatment
- ERCP stenting
- Choledocho-duodenostomy/jejunostomy
- Roux-en-Y hepaticojejunostomy