Introduction
Cholangitis is inflammation of the
bile duct. It is typically the
results of a bacterial infection (often secondary to
gallstones), but can also occur in other conditions, such as
primary sclerosing cholangitis and
Caroli’s Syndrome. It may also be present in malignancies of the biliary system.
- In cases where bacterial infection is the cause, it is called ascending cholangitis.
Acute Ascending Cholangitis
Has a high mortality and morbidity, especially in old people.
Presentation – rigors, fever, abdominal pain, jaundice
Treatment
It is a medical emergency.
- IV antibiotics – usually cephalosporin- e.g. cefotaxime
- Urgent biliary drainage – Endoscopically - usually access to the biliary tree is gained by sphincterotomy, and then stones removed with a balloon catheter. Successful in 90% of patients.
- In severely ill patients, stenting may be used in place of stone removal, to reduce peri-operative risk whilst still providing drainage. Stones will later be removed via ERCP.
- Surgical drainage carries an extremely high mortality, and is reserved for those with whom endoscopic methods are not effective
Acute Cholecystitis
This is caused by a
blockage in the cystic duct or neck of the gallbladder (95% of cases are
gallstones or gallstone precursor ‘
sludge’)
It is
unlikely to be infection, and more likely to be local inflammation. You can also get associated
peritonitis.
The obstruction causes an increase in mucus secretions from the gallbladder, which causes gallbladder distension, and may affect the blood supply to the gallbladder.
The initial event in cholecystitis is often an obstruction to gallbladder emptying. In 95% of cases, a gallstone is the cause! It is different to biliary colic because it is not a problem in the bile duct, but a problem in the gallbladder or the cystic duct.
Occasionally the obstruction is due to mucus (e.g.
CF)
, worms or a tumour.
The obstruction will cause an increase in gallbladder secretion which leads to distension of the bile ducts. This has two effects; it can obstruct the blood flow to the gallbladder, as well as initiating an inflammatory response to the bile retained in the gallbladder. This can lead to mucosal damage, which in turn leads to the release of phospholipase, which converts lecithin into lysolecitihin, which is a very potent toxin.
Infection will occur in about 50% of patients by the time of surgery.
Symptoms
- Similar to those of biliary colic, and often differentiation is difficult. Cholecystitis often results in a more prolonged pain with a fever and leukocytosis.
- ↑WCC – in cholecystitis, but not in biliary colic.
- Murphy’s Sign. There will be RUQ pain that is usually worse on inspiration. Murphy’s sign is where you would put your hand under the patient’s ribs and ask them to breathe in. As they do so, their gallbladder will be forced down against your hand, and it will cause them a lot of pain!
- Only a positive result if the sign is negative in the LUQ!
- Jaundice (in <10% of patients)
- The pain is more likely to radiate to the shoulder tip in this than is other biliary conditions because the radiation is caused by irritation of the diaphragm and this is more likely in cholecystitis.
Investigations
- Full blood count – ↑ESR, ↑CRP, ↑WCC
- Serum amylase – ↑- acute pancreatitis may be present as a complication of gallstones.
- Serum bilirubin, alkaline phosphatase and amino transferase may all be slightly raised.
- The bile duct will often be dilated to >8mm
- USS – may detect:
- Gallstones
- Gallbladder wall thickening
- Dilated common bile duct (>6mm)
Management
- Nil By Mouth
- Bed rest
-
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