Ascending Cholangitis History

Abdominal pain – 70% of patients
• In the right upper side or middle of the upper abdomen
• May come and go
• Pain is sharp, crampy, or dull
• Pain may move to the back or below the right shoulder blade
Fever – 90% of cases
Jaundice – 60% of cases
Rigors(uncontrollable shaking) and a feeling of uneasiness (malaise), pruritis, acholic or hypocholic stools - stools look clay like
Charcot's triad - abdominal pain, jaundice, and fever - 15–20% of cases.
Reynolds' pentad includes the findings of Charcot's triad with hypotension (30% of cases) and mental confusion (10-20% of cases). This combination of symptoms indicates worsening of the condition and the development of septicemia – less common than Charcot’s triad
In the elderly, the presentation may be atypical; they may directly collapse due to septicemia without first showing typical features.
Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain.
Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.
• The patient's medical history may be helpful. For example, a history of the following increases the risk of cholangitis:
• Gallstones, CBD stones
• Recent cholecystectomy
• Endoscopic manipulation or ERCP, cholangiogram
• History of cholangitis
• History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidium infections. The management of this condition is described below, although decompression is usually not necessary.

Management of Cholecystitis and Cholangitis

Management of Cholecystitis

Medical Care
For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species. Emesis can be treated with antiemetics and nasogastric suction.

Antiemetics:
o Promethazine (Phenergan, Prorex, Anergan). For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent
o Prochlorperazine (Compazine). May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects

Analgesics:
o Meperidine (Demerol) DOC. Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. Doesn’t affect sphincter of Oddi as much
o Vicodin

Antibiotics
o Ciprofloxacin (Cipro) Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material.
o Meropenem (Merrem) Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
o Imipenem and cilastatin (Primaxin) For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.

Surgical Care
Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis.
For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. Some considerations regarding cholecystectomy include the following:
•Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.
•Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.
•For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.
•Contraindications for laparoscopic cholecystectomy include the following:
oHigh risk for general anesthesia
oMorbid obesity
oSigns of gallbladder perforation, such as abscess, peritonitis, or fistula
oGiant gallstones or suspected malignancy
oEnd-stage liver disease with portal hypertension and severe coagulopathy

Treatment for gall stones
Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but it may be required that the patient takes this medication for up to two years. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure called lithotripsy (extracorporeal shock wave lithotripsy) which is a method of concentrating ultrasonic shock waves onto the stones to break them into tiny pieces. They are then passed safely in the feces. However, this form of treatment is only suitable when there are a small number of gallstones.

ERCP: technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.

Cholangitis
Prehospital Care
Diagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice, and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line.
In unstable patients with cholangitis, prehospital care should include the following:
•Immediate assessment of ABCs
•Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
•Stabilization (eg, oxygen, administration of IV fluids to unstable patients)
•Rapid transport

Emergency Department Care
•After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG.
•Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).
•Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
•Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree.
•Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.
•In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness. In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
•Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below.
•The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage.

Medication
It is critical that antibiotics are administered early in the management of cholangitis. In the ED, empiric antibiotic therapy should cover against gram-negative aerobic enteric organisms (eg, E coli, Klebsiella species, Enterobacter species), gram-positive organisms (eg, Enterococcus and Streptococcus species), and anaerobes (eg, Bacteroides fragilis, Clostridium perfringens). There is an increase of up to 85% in infectious complications when biliary cultures are not susceptible to the empiric antibiotics.
Many newer combinations have been shown to be effective as either a single agent or combination therapy. Combinations include extended-spectrum cephalosporin, metronidazole, and ampicillin. Single-agent regimens include piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam, which can also be combined with metronidazole.
In patients with few comorbidities and who are well-appearing, using a single agent such as cefoxitin (second-generation cephalosporin) may be appropriate. However, cefoxitin’s anaerobic coverage is poor. Newer-generation fluoroquinolones (eg, moxifloxacin) also have broad gram-positive and gram-negative coverage and better anaerobic activity, but they are poorly effective against Pseudomonas species. In patients with multiple comorbidities or who are ill-appearing, broad-spectrum antimicrobials with pseudomonal and enterococcal coverage are recommended.

Complications of Cholangitis

o Liver failure, hepatic abscesses, and microabscesses- chronic inflammation of the bile ducts throughout your liver can lead to tissue scarring (cirrhosis), liver cell death and, eventually, the inability of your liver to function properly.

o Bacteremia (25-40%); gram-negative sepsis

o Acute renal failure

o Repeated infections. If scarring of the bile ducts impairs the flow of bile out of the liver, you may experience frequent infections in the bile ducts.

Cholecystitis and Cholangitis

Definition of Cholecystitis
• It is defined as inflammation of the gallbladder.
• The Inflammation can be sterile or bacterial. (50-75% of cases)
• Occur most commonly due to obstruction of the cystic duct from cholelithiasis(gallstones, 90%). Remaining 10% are a calculous.
• More common in females by 2-3 times and increases with age.
• "fair, female, fat, and fertile" RF of cholecystitis.
• It is said that less common in Asia because of decrease choleithiasis incidence. If there are pigmented stones are more common compared to cholesterol stones.

Pathophysiology of Cholangitis
• Etiology – Biliary tract obstruction, Elevated intraluminal pressure, Infection of bile, Biliary tract manipulation/stents and Autoimmune (chronic liver disease).
• Biliary tract obstruction +Bacterial ascend from duodenum or portal venous blood  Diminish host antibacterial defences  Increase small bowel bacterial colonization
• Increase biliary pressure  Push infection into biliary canaliculi, hepatic veins and lymphatics  Bacteremia (25-40%),
• Autoimmune  Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts  Portal hypertension and cirrhosis.