Cholangitis

Question 1

What is acute cholangitis?

Answer 1

infection and inflammation in the bile ducts.

It is a surgical emergency and has a high mortality due to sepsis and septicaemia.

Question 2

2 main causes of acute cholangitis

Answer 2

1.Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)

2.Infection introduced during an ERCP procedure

Question 3

Epidemiology of Acute (ascending) cholangitis

Answer 3

Age >50
M=F
Rare
White, hispanics and Native americans

Question 4

Aetiology of Acute cholangitis

Answer 4

• Choledocholithiasis, stones in the bile duct, is the most common cause of acute cholangitis.
• Benign stricture: leading to obstruction, may occur in the biliary tree for numerous reasons
• Malignant stricture: e.g. cholangiocarcinoma, pancreatic cancer and gallbladder cancer.

Question 5

RFs for acute cholangitis

Answer 5

• Gallstones:the most common predisposing factor
• Stricture of the biliary tree:benign or malignant
• Post-procedure injuryof the bile ducts e.g. post-ERCP

Question 6

Pathophysiology of Acute cholangitis

Answer 6

• Due to bacterial infection secondary to biliary obstruction
• Bilary obstruction due to gallstones in bililary tree
• Obstruction > cholestasis and growth of bacteria - gram negative

Question 7

Most common organisms that cause acute cholangitis?

Answer 7

Escherichia coli
Klebsiella species
Enterococcus species

Question 8

What is Charcot’s Triad?

Answer 8

Acute cholangitis presents with Charcot’s triad:

Right upper quadrant pain
Fever
Jaundice (raised bilirubin)

Question 9

What is the management for acute cholangitis

Answer 9

need emergency admission for investigations and management.
Patients need acute management of sepsis and acute abdomen, including:

Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
Involvement of seniors and potentially HDU or ICU

Question 10

First line investigation for acute cholangitis

Answer 10

• FBC:leukocytosis with neutrophilia
• LFTs:obstructive jaundice with raised ALP > ALT, and bilirubin
• U&Es: pre-renal acute kidney injury in sepsis
• CRP: acute-phase protein and marker of inflammation
• ## VBG: assess for acidosis and lactate if suspecting sepsis

Question 11

What imaging do we use to diagnose common bile duct (CBD) stones and cholangitis?

Answer 11

Abdominal ultrasound scan
CT scan with IV contrast
Magnetic resonance cholangio-pancreatography (MRCP) - GS
Endoscopic ultrasound

Question 12

DDs for ascending acute cholangitis

Answer 12

• Acute cholecystitis
• Peptic ulcer disease
• Pancreatitis
• Appendicitis

Question 13

What procedure is done to remove stones blocking the bile duct?

Answer 13

endoscopic retrograde cholangio-pancreatography (ERCP)

Question 14

What happens during an ERCP?

Answer 14

involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system.

Question 15

What is a Percutaneous transhepatic cholangiogram (PTC)?

Answer 15

involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts.

Question 16

What does a PTC do?

Answer 16

drain relieves the immediate obstruction.

A stent can be inserted to give longer-lasting relief of obstruction.

This is an option for patients that are less suitable for ERCP, or where ERCP has failed.

Question 17

What is primary sclerosing cholangitis? (PSC)

Answer 17

immune mediated chronic liver disease where the intrahepatic or extrahepatic bile ducts become inflammed, fibrotic and destroyed.

Question 18

What does PSC cause?

Answer 18

causes an obstruction to the flow of bile out of the liver and into the intestines.

Sclerosis refers to the stiffening and hardening of the bile ducts, and cholangitis is inflammation of the bile ducts.

Chronic bile obstruction eventually leads to liver inflammation (hepatitis), fibrosis and cirrhosis.

Question 19

What causes PSC?

Answer 19

Combo of genetic, autoimmune, intestinal microbiome and environmental factors

Established association with ulcerative colitis -70% of cases associated with this.

Question 20

Epidemiology of PSC

Answer 20

• It is more common in Northern Europe and North America.
• Male sex:two-fold more common in males than females
• Age 40-50 years:

Question 21

PSC risk factors

Answer 21

Male
Aged 40-50
Ulcerative Colitis
Family History
HLA-A1, B8 and DR3

Question 22

Presentation of PSC

Answer 22

Jaundice
Chronic right upper quadrant pain
Pruritus
Fatigue
Hepatomegaly

Question 23

Pathophysiology of PSC

Answer 23

AI trigger > intra + extrahepatic bile duct damage > bile duct strictures + Bile and toxins in liver= cirrhosis> Retained toxic bile acids in liver > Liver fibrosis, cirrhosis and end-stage liver disease

Question 24

Primary investigations of PSC

Answer 24

• LFTs - raised ALP and raised bilirubin, raised GGT, raised ALT and AST if liver damage present, decreased albumin.
• Viral hepatitis screen:screen for HBsAg and anti-HCV in all patients
• Antibodies screening:
  
  • pANCA Anti-neutrophil cytoplasmic antibodies: positive in 33-88% of PSC patients, however is not specific
• MRCP

Question 25

What is the gold standard investigation for diagnosis of PSC?

Answer 25

MRCP - magnetic resonance cholangiopancreatography involves an MRI scan of the liver, bile ducts and pancreas. In primary sclerosis cholangitis it may show bile duct lesions or strictures.

Question 26

Associations and complications of PSC?

Answer 26

Acute bacterial cholangitis Cholangiocarcinoma develops in 10-20% of cases Colorectal cancer Cirrhosis and liver failure Biliary strictures Fat soluble vitamin deficiencies

Question 27

Management of PSC

Answer 27

ERCP can be used to dilate and stent any strictures Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids Healthy life + Fat soluble vitamin supplementation

Question 28

What happens when the cells in the bile ducts become inflamed in PSC?

Answer 28

- Cells die and harden due to fibrosis - get this tightening of the ducts in some areas where there’s been serious fibrosis and then dilation in other areas that aren’t as affected, and this leads to the classic PSC finding of this sort of “beaded” appearance of the bile ducts.

Question 29

What is PSC most likely to be and caused by?

Answer 29

Certain genetic factors have been linked to developing PSC; studies have shown that patients with PSC tend to have in common specific human leukocyte antigens, or HLAs. most patients with PSC have elevated IgM antibody levels in the serum, as well as an antibody called p-ANCA.

Question 30

What are the symptoms of PSC similar to?

Answer 30

obstructive jaundice, since these “beads” or pinched areas are obstructing the flow of bile. as these epithelial cells lining the ducts die off, bile can now be allowed to leak out past the cells into the interstitial space, where it can access the bloodstream.

Question 31

How does PSC cause portal hypertension

Answer 31

- Inside the liver, the intra-hepatic bile ducts are in close proximity to portal veins - So as fibrosis builds up around the bile ducts, it constricts the portal veins as well and higher pressures develop in the veins, leading to a condition called portal hypertension.

Question 32

How can it cause hepatosplenomegaly?

Answer 32

Portal hypertension cause backup of fluid in the spleen and liver and therefore cause enlargement of both, also known as hepatosplenomegaly.

Question 33

How can cirrhosis occur in PSC?

Answer 33

Over time, as fibrosis and scar tissue progress in the intrahepatic bile ducts, patients can develop cirrhosis, where the liver stops functioning right from this damage.

Question 34

Cholangiocarcinoma and PSC:

Answer 34

due to the constant damage to bile ducts, patients often have a higher risk of cholangiocarcinoma.