Acute Cholangitis without a Gallbladder

Today, Dr. Nakache presented a case of a 63yoF with a history of cirrhosis and cholecystectomy who presented with RUQ pain and sepsis with EColi bacteremia, found to have acute cholangitis.

Causes of Acute Cholangitis: Stones, strictures, malignancy, stent occlusion, s/p ERCP, postoperative (Whipple, gastric bypass, etc), or extrinsic compression (Lemme’s syndrome, acute pancreatitis, Mirizzi syndrome), parasites (liver flukes or ascaris)

Symptoms/signs: 

Charcot’s triad: Fever, jaundice, abdominal pain (only 50-75% have this triad)

Reynold’s pentad for severe cholangitis: Charcot’s triad + hypotension and AMS

Complications: septic shock, hepatic abscess, multiple organ dysfunction

Labs: Leukocytosis/evidence of infection, Cholestatic LFTs, although can also get transaminitis if hepatocyte necrosis (high 2000s, consider liver abscess)

Diagnosis:

Must meet all criteria:

  1. Evidence of systemic inflammation: Fever, shaking chills, leukocytosis, elevated CRP
  2. Evidence of cholestasis (Tbili >= 2, elevated LFTs 1.5x ULN)
  3. Imaging with biliary dilation OR evidence of cause (stones, stricture, etc.

Choice of Imaging:

Start with abd US. If negative but still very high clinical suspicion, get abd CT. If negative, but still very high clinical suspicion, get MRCP. These tests get more expensive, more time consuming, and more sensitive as you go down the list.

Caveat #1: If the patient’s is s/p cholecystectomy, abdominal ultrasound may be too nonspecific due to normal postoperative biliary dilation. Visualization of the distal CBD is also particularly poor on ultrasound.

Treatment:

  1. Supportive care (fluids, electrolyte repletion, analgesia)
  2. Antibiotics
  3. Biliary drainage via ERCP, which is successful 90-95% of cases
  4. Address the cause (consider cholecystectomy if 2/2 stones, consider stenting if due to malignancy)

Antibiotic treatment:

If infection is community acquired without risk factors for antibiotic resistance, use one of the following regimens:

– Zosyn

– Cephalosporin + Flagyl

– Cipro or Levofloxacin + Flagyl

If the patient shows signs of end-organ damage, is in septic shock, OR there are risk factors for antibiotic resistance (recent travel to Asia, Africa, or Middle East, known colonization with antibiotic resistant organisms, or healthcare-acquired infection), use one of the following regimens:

– Zosyn

– Carbapenem: Meropenem or Imipenem + cilastatin or Doripenem

– Cefepime or ceftazidime + Flagyl

Duration of Therapy:

Continue antibiotics until 4-5 days after source control.

Timing of ERCP:

70-80% of cholangitis patients respond to initial therapy and ERCP can be done nonemergently within 24-48 hours.

If they shows signs of end organ damage, are in septic shock, or do not respond to 24 hours of antimicrobial therapy and supportive care, they should get ERCP emergently within 24 hours.

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