Acute Cholangitis

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Acute Cholangitis

• Acute biliary sepsis in the presence of an
  obstructed or partially obstructed biliary
  system
• Variable mild to life threatening infection
  which can be rapidly fatal

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Recurrent Cholangitis

• Recurrent episodes of bacterial biliary sepsis
  caused by
• Stones
• Strictures
• Foreign bodies e.g., stents

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Bacteriology

• 80 patients G/S cholangitis ve cultures
• E.Coli (commonest)
• Klebsiella sp
• Enterococci
• Proteus sp
• Pseudomonas sp
• Bacteroides sp

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Bile Bacteriology

• Multiple organisms frequent
• Anaerobes commoner in patients with bilio-enteric
  anastomosis (HJ)
• Combined infection associated with a more severe
  clinical condition

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Bacteriology

• Blood cultures most commonly grow E.Coli and
  Klebsiella sp.
• Anaerobes and enterococci are rarely isolated
  from blood cultures.

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Clinical presentation

• Charcots triad
• Pyrexia, Pain, Jaundice
• Rigors
• NV
• In severe sepsis, the patient can be moribund

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Common causes

• Infected / Obstructed system due to
• Gallstones
• Stricture
• Stent insertion

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Investigations

• FBC / UE / LFT
• Blood cultures
• US scan ? obstruction or abscess
• Abscess suspected on US, do CT

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Management

• Rehydrate, CVP if necessary
• Monitor urine output
• Intravenous broad spectrum antibiotics -
  Cefuroxime Metronidazole
• - Ciprofloxacin
• - GentamicinAmpicillinMet

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Critically ill

• May need HDU inotropes
• ITU and ventilation
• Biliary drainage essential
• Urgent ERCP or PTC

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Antibiotic prophylaxis

• Not required if biliary system drained
• Not shown to reduce the incidence of stent
  blockage
• Useful with Biliary- enteric anastomoses
• Cephalexin (effective and excreted in bile)
• Ampicillin, trimethoprim

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Stents

• Usually temporary in benign disease
• Definitive treatment in inoperable malignant
  disease
• Metal stents have a lower incidence of blockage
• Adequately drained systems do not need
  prophylaxis

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Stones

• Remove stones via ERCP or Surgery
• Elderly high risk patients, stents may be used
  for drainage
• Antibiotic prophylaxis essential

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Strictures

• Benign strictures - temporary stent
• Surgical repair treatment of choice
• Operable malignant strictures may be temporarily
  stented
• Antibiotic prophylaxis often needed
• 20 complication rate preop stents

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External biliary drainage

• Associated with higher infection rates than
  internal drainage
• Temporary external drains should have antibiotic
  prophylaxis

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Summary

• Treat acute episode aggressively
• Adequately drained biliary systems rarely cause
  problems
• AB prophylaxis rarely required