Remember that Acute Cholangitis is a medical emergency that must be recognized and treated emergently!

CBD diameter

Remember that CBD diameter can be a clue to biliary obstruction
-95 % of normal patients have a CBD < 6 mm
-Can increase with age, usually upper limit corresponds to decade of life (70 year old upper limit of ~ 7 mm
-Can see CBD up to 10 mm if post-cholecystectomy!

If you suspect choledocholithiasis, the ASGE guidelines can help you decide whether you should do an MRCP or an ERCP

-Remember if you have any very strong predictors (see below), you should go directly to an ERCP!

Very strong predictors of choledocholithiasis

-CBD stone seen on trans abdominal ultrasound
-Bilirubin>4 mg/dl
-Clinical ascending cholangitis

MRCP vs. ERCP

MRCP=diagnostic modality, NO contrast given, excellent sensitivity to evaluate for choledocholithasisis (90-100%)
ERCP=diagnostic and therapeutic modality, invasive (have to be in prone position!), risk of post-ERCP pancreatitis

Four main etiologies of biliary obstruction

–Choledocholithasis (MCC)
-Biliary strictures
-Malignancies
-Biliary stent complication (eg: migration)

Etiology
GUT FLORA

-E.Coli (most common), Klebsiella, Enterobacter, Enterococcus, and Anaerobes (less common alone)

Key Clinical manifestations and lab findings for cholangitis and which ones are most common

-Fever (95 %)
-RUQ pain (90 %)
-Jaundice (80 %)
Charcot’s Triad=>Fever, RUQ, Jaundice
(+) Hypotension, Confusion, Leukocytosis, Cholestatic jaundice.

Treatment for empiric coverage for cholangitis

-Beta Lacam/Beta Lactamase inhibitor
-Flouroquinolone + Flagyl
-Carbapenem

Management for cholangitis in addition to antibiotics

-ERCP for source control, treatment of sepsis, and cholecystectomy