CHOLANGITISCHOLANGITIS

Reported by: R. DongaranReported by: R. Dongaran

DEFINITIONDEFINITION

The term The term cholangitischolangitis means inflammation of the means inflammation of the bile ducts. bile ducts.

The term applies to inflammation of any portion The term applies to inflammation of any portion of the bile ducts, which carry bile from the liver to of the bile ducts, which carry bile from the liver to the gallbladder and intestine. the gallbladder and intestine.

The inflammation is produced by bacterial The inflammation is produced by bacterial infection or sometimes other causes.infection or sometimes other causes.

Obstruction and infection in the common bile duct Obstruction and infection in the common bile duct cause Charcot's triad: jaundice, right upper cause Charcot's triad: jaundice, right upper quadrant pain, and a high fever with chills.quadrant pain, and a high fever with chills.

BACKGROUND OF STUDYBACKGROUND OF STUDY

Two things that are needed for cholangitis Two things that are needed for cholangitis to occur to occur

1) obstruction to bile flow1) obstruction to bile flow2) presence of bacteria within the bile 2) presence of bacteria within the bile ducts. ducts.

The most common cause of cholangitisThe most common cause of cholangitis is is infection of the bile ducts due to blockage infection of the bile ducts due to blockage by a gallstone.by a gallstone.

The bacterium most commonly associated The bacterium most commonly associated with infection of the bile ducts is with infection of the bile ducts is Escherichia Escherichia coli (E. coli)coli (E. coli) which is a normal inhabitant of which is a normal inhabitant of the intestinethe intestine

Another type of bile duct infection occurs Another type of bile duct infection occurs mainly in Southeast Asia and is known as mainly in Southeast Asia and is known as recurrent pyogenic cholangitis or Oriental recurrent pyogenic cholangitis or Oriental cholangitis. cholangitis.

It has also been identified in Asians It has also been identified in Asians immigrating to North America. Most immigrating to North America. Most patients have stones in the bile ducts and/or patients have stones in the bile ducts and/or gallbladder, and many cases are associated gallbladder, and many cases are associated with the presence of parasites within the with the presence of parasites within the ducts. ducts.

The role of parasites in causing infection is The role of parasites in causing infection is not clear. Many researchers believe that not clear. Many researchers believe that they are just coincidental, and have nothing they are just coincidental, and have nothing to do with the stones or infection.to do with the stones or infection.

RISK FACTORRISK FACTOR

Individuals who are at greater risk are those who have Individuals who are at greater risk are those who have previously suffered from gallstones, biliary diseases such previously suffered from gallstones, biliary diseases such as:as:

Sclerosing CholangitisSclerosing Cholangitis PrimaryPrimary -- SecondarySecondary --

HIV, and rarely, travel to countries where a worm or fluke HIV, and rarely, travel to countries where a worm or fluke infection can be contracted. (unusual organism infection can be contracted. (unusual organism CryptosporidiumCryptosporidium))

SEXSEX Cholangitis occurs more commonly in women than men. Cholangitis occurs more commonly in women than men.

AGEAGE The onset is usually after age 55.The onset is usually after age 55.

Elderly patients more likely to progress from asymptomatic Elderly patients more likely to progress from asymptomatic gallstones to cholangitis without colic.gallstones to cholangitis without colic.

SIGN AND SYMPTOMSSIGN AND SYMPTOMS

recurrent recurrent jaundice abdominal pain

in the right upper quadrant or middle of the in the right upper quadrant or middle of the upper abdomen upper abdomen

may be recurrent may be recurrent sharp or cramping or dull sharp or cramping or dull may radiate to the back or below the right may radiate to the back or below the right

shoulder blade shoulder blade fever chills chills stools, clay colored (may occur) stools, clay colored (may occur) dark urine (may occur) dark urine (may occur) nausea nausea vomiting vomiting

DIAGNOSTIC TESTDIAGNOSTIC TEST

1. Blood tests1. Blood tests, including the following:, including the following: complete blood count (CBC)complete blood count (CBC) liver function testsliver function tests blood culturesblood cultures

2. Cholangiography2. Cholangiography

- - x-ray examination of the bile ducts using an x-ray examination of the bile ducts using an intravenous intravenous (IV) dye (contrast).(IV) dye (contrast).

3. 3. Percutaneous Transhepatic Cholangiography Percutaneous Transhepatic Cholangiography (PTC)(PTC)

-- a needle is introduced through the skin and a needle is introduced through the skin and into into the liver the liver where the dye (contrast) is deposited and where the dye (contrast) is deposited and the bile duct the bile duct structures can be viewed by x-ray.structures can be viewed by x-ray.

4. Endoscopic retrograde cholangiopancreatography 4. Endoscopic retrograde cholangiopancreatography (ERCP)(ERCP)

-- a procedure that allows the physician to diagnose a procedure that allows the physician to diagnose and and treat problems in the liver, gallbladder, bile ducts, treat problems in the liver, gallbladder, bile ducts, and and pancreas. pancreas.

5. Ultrasound (Also called sonography)5. Ultrasound (Also called sonography)

-- a diagnostic imaging technique which uses high-a diagnostic imaging technique which uses high-frequency sound waves to create an image of the frequency sound waves to create an image of the internal internal organs. organs.

MEDICAL TREATMENTMEDICAL TREATMENT

1.1. Resucitate, Monitor, Stabilize if patient unstableResucitate, Monitor, Stabilize if patient unstableConsider cholangitis in all patients with sepsisConsider cholangitis in all patients with sepsis

2.2. AntibioticsAntibiotics

Empiric broad-spectrum Abx after blood cultures Empiric broad-spectrum Abx after blood cultures drawndrawn

a.a. Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)daily)

b.b. Carbapenems: gram negative, enterococcus, Carbapenems: gram negative, enterococcus, anaerobesanaerobes

c.c. Levofloxacin (250-500mgIV qD) for impaired renal Levofloxacin (250-500mgIV qD) for impaired renal fxn. 80% of patients can be managed fxn. 80% of patients can be managed conservatively 12-24 hrs Abxconservatively 12-24 hrs Abx

If fail medical therapy, mortality rate 100% If fail medical therapy, mortality rate 100% without without surgical decompression: ERCP or opensurgical decompression: ERCP or open

Indication: persistent pain, hypotension, Indication: persistent pain, hypotension, fever, mental fever, mental confusionconfusion

SURGICAL TREATMENTSURGICAL TREATMENT

Extracorporeal Shock-wave LithotripsyExtracorporeal Shock-wave Lithotripsy

(ESWL) (ESWL)

was first used to break up kidney was first used to break up kidney stones. stones.

The technique has been extended The technique has been extended to the treatment of gallstones, in to the treatment of gallstones, in bothboth

the gallbladder and bile ducts.It is the gallbladder and bile ducts.It is often combined with endoscopicoften combined with endoscopic

proceduresprocedures To ease the passage of To ease the passage of

fragmented stones, or oral fragmented stones, or oral medications that can dissolve the medications that can dissolve the fragments. Rarely, stones are also fragments. Rarely, stones are also dissolved by instilling various dissolved by instilling various chemicals such as ether directly chemicals such as ether directly into the bile ducts.into the bile ducts.

Endoscopic sphincterotomy or endoscopic retrograd Endoscopic sphincterotomy or endoscopic retrograd esphincterotomy (ERS)esphincterotomy (ERS)

With stone extraction and stent insertion is a With stone extraction and stent insertion is a relatively new endoscopic relatively new endoscopic technique developed to examine technique developed to examine and treat abnormalities of the bile and treat abnormalities of the bile ducts, pancreas and ducts, pancreas and gallbladder.gallbladder.

Sphincterotomy, which means cutting of the sphincter Sphincterotomy, which means cutting of the sphincter or muscle that or muscle that lies at the juncture of the intestine with lies at the juncture of the intestine with both the bile and pancreatic both the bile and pancreatic ducts.ducts.

CBD stones removed in 90-95% of cases therapeutic CBD stones removed in 90-95% of cases therapeutic mortality 4.7% and mortality 4.7% and morbidity 10%, lower than surgical morbidity 10%, lower than surgical decompressiondecompression

COMPLICATIONCOMPLICATION SepsisSepsis Alkaline Phosphatase Live Isoenzyme Alkaline Phosphatase Live Isoenzyme Levels Raised (Plasma or Serum)Levels Raised (Plasma or Serum) Pyrexia of unknown originPyrexia of unknown origin Urobilinogen levels raised (Urine)Urobilinogen levels raised (Urine) Liver AbscessLiver Abscess Abdominal PainAbdominal Pain Cholestatic JaundiceCholestatic Jaundice

NURSING MANAGEMENTNURSING MANAGEMENT Check the patient's vital signs often, especially if his Check the patient's vital signs often, especially if his

chills result from a known or suspected infection. chills result from a known or suspected infection.

Be alert for signs of progressive septic shock, such as Be alert for signs of progressive septic shock, such as hypotension, tachycardia, and tachypnea. hypotension, tachycardia, and tachypnea.

Obtain samples of blood, sputum, wound drainage, or Obtain samples of blood, sputum, wound drainage, or urine for culture to determine the causative urine for culture to determine the causative organism. organism.

Give the appropriate antibiotic. Give the appropriate antibiotic.

Prepare the patient for radiographic studies, as Prepare the patient for radiographic studies, as required.required.

Keep the room temperature as even as possible. Keep the room temperature as even as possible.

Provide adequate hydration and nutrients. Provide adequate hydration and nutrients.

Administer an antipyretic to help control a fever. Administer an antipyretic to help control a fever.

PATIENT’S TEACHINGPATIENT’S TEACHING

Explain the importance of documenting Explain the importance of documenting temperature readings and times to temperature readings and times to reveal patterns. reveal patterns.

Teach him about his diagnosis and Teach him about his diagnosis and treatment, especially about the treatment, especially about the importance of taking the full course of importance of taking the full course of antibiotics. antibiotics.

Explain the signs and symptoms of a Explain the signs and symptoms of a worsening condition and when to seek worsening condition and when to seek medical attention.medical attention.