Cholangitis

00:01 Hello there. This talk is about cholangitis. So, inflammation of the biliary tree.

00:07 And it can affect anything from the enteropathic portion of the biliary tree, the common bile duct, the cystic duct, all the way down into the duodenum where we dump all the contents of what is being synthesized by the liver.

00:24 The epidemiology of this overall, it is not uncommon but not super common, about three to four patients per 1000 population.

00:33 Interestingly, because a lot of biliary disease is more common in women than in men, the gender predilection is about the same for the inflammation of the biliary tree.

00:45 It is much more common in the geriatric population, people over than 50.

00:50 And surprisingly, has relatively high mortality, so, you don't mess around with cholangitis.

00:58 In the pathophysiology, there is a long litany of causes.

01:03 The vast majority, well, the majority are going to be choledocholithiasis.

01:07 That means stones in the common bile duct.

01:10 You can have benign biliary strictures that are due to past bouts of inflammation or maybe even congenital. Malignancy is a significant cause, up to 30% of causes of cholangitis, so, cholangiocarcinoma. Inflammatory lesions, sclerosing cholangitis or ascending cholangitis can all be causes.

01:35 Extrinsic compressions, say, a pancreatic pseudocyst or acute pancreatitis down at the point where the common bile duct enters into the duodenum.

01:45 Certain parasites, kind of like the biliary tree, so, Ascaris, a round worm, Ascaris lumbricoides can be a cause of cholangitis and clearly, past bouts of infectious or postoperative occlusions, strictures, will be a cause of cholangitis as well. It's not just the inflammation.

02:07 It's actually the bacteria that can get into these areas of relative inflammation and it's going to be any of the hosts of the typical enterics.

02:16 E. coli is going to be probably isolated in about half of the cases but anything that lives in the GI tract can get into the biliary tree and cause inflammation. Kind of a general schematic for how this is happening.

02:33 So, you can have, in this particular case, we have a stone that is in the common bile duct that is causing a partial occlusion and things proximally become dilated and inflamed.

02:44 Now, that stone may not be completely occlusive and with squeezing, say, of the duodenum and its normal peristaltic motion, we can get retrograde movement of bile and/or GI contents, including bacteria, past the area of stone into that obstructed portion of the biliary tree.

03:05 That will then lead to infection, inflammation, and an overall worsening scenario.

03:11 The clinical presentation. So, there's a classic Charcot's triad.

03:15 Again, I mean, this is to be what you would expect if there's inflammation within the biliary tree.

03:21 There'll be right upper quadrant abdominal pain. There'll be fever and jaundice.

03:25 This can clearly be a lot of other things as well.

03:29 So, simply having this doesn't mean you nail that diagnosis of cholangitis.

03:34 There is a Reynold's pentad. So, we had a Charcot's triad. That's the first three up there.

03:38 And then, by the Reynold's pentad, we'll add hypotension and altered mental status.

03:44 That's when things are really getting bad. So, we're getting a septic physiology.

03:49 Other features including nausea and vomiting, abdominal distention.

03:53 We're not moving bile into the stool, so, it's going to be clay colored, light colored stools.

03:59 We will see increased amounts of bilirubin and metabolites that are going to be in the urine.

04:05 And so, it's a darker urine. And with the accumulation of bile salts under the skin, you're going to have pruritus.

04:12 So, none of these are going to be absolutely specific for cholangitis but they can point you in that general direction.

04:20 Making the diagnosis, combination of laboratories. It's mostly the imaging. So, it's an angiitis.

04:27 It is an inflammation. So, we're going to see an elevated white count with the left shift elevated neutrophils. We're going to see evidence of obstruction.

04:34 We've talked about this in many of our other talks having to do with the liver and the biliary tree.

04:39 But we're going to see elevated alkaline phosphatase because that's a reasonably good marker of biliary obstruction.

04:48 Bilirubin is also probably elevated because we're not draining it into the GI system, into the GI tract.

04:56 It's going to be a direct hyperbilirubinemia. So, it is going to be conjugated.

05:01 We will also see some modest elevation of the gamma glutamyl transpeptidase indicating some hepatocyte injury.

05:08 But overall, we look at the transaminases, their elevation is going to be mild if at all.

05:15 If we see an elevated lipase, that means we have concurrent pancreatitis and things just got a whole lot worse for our patient. So, we have a cholangitis and pancreatitis.

05:24 Not looking good. And blood cultures will help us, particularly, if we now have sepsis with a bacteremia.

05:32 And that will help us in terms of tailoring our antibiotics appropriately to treat what's going on in terms of infection.

05:41 So, abdominal ultrasound is going to be your go to diagnostic modality.

05:46 It's going to demonstrate bile duct dilation.

05:48 It will also show that there's thickening of the biliary tree.

05:52 It may demonstrate a particular stone and this is really what you're going to use to kind of nail the final diagnosis.

06:01 CT and MRI can also be used, not as sensitive overall. How are you going to manage this? Well, this is an infection, inflammation of the biliary tree.

06:13 We're going to have to be very aggressive because it does have a high mortality.

06:19 So, beyond supportive therapy, fluid resuscitation, vasopressors for sepsis, antiseptic shock, pain control, etc., we want to give appropriate antibiotics that's based on blood culture results and we want to decompress the biliary tree.

06:33 So, that may be a percutaneous stent that is performed by interventional radiology but surgery is going to be something we need to do and because the majority of these are going to be associated with a stone, we're going to have to probably carve out the gallbladder and portions of the biliary tree, a cystic duct, to get rid of the source, potentially, for the calculus cholecystitis that is driving this.

07:02 In many cases, you'll have to wait until this is kind of defervesced.

07:06 So, you would want to make sure that you don't have a markedly, you don't have a septic bed with pus there.

07:14 You want to make sure that we treat it, calm it down a lot with antibiotics, analgesia and time, and then, go in and surgically correct it.

07:23 The mortality rate is overall about 10% with really severe disease such as a perforation or involving the pancreas with pancreatitis, it can be up to 30%.

07:35 The people who are at greater risk are women older than 50.

07:40 If there's underlying liver disease such as cirrhosis, if you don't respond to the antibiotics or maybe have the wrong antibiotic for the bug that's there.

07:47 If you develop secondary liver abscess with kind of an ascending infection into the liver or acute renal failure associated with sepsis or hepatorenal syndrome, all those are worse in terms of the overall prognosis.

08:02 And with that, we have covered the cholecystitis and cholangitis.