Table 18.1 Nomenclature of bone tumors
Cholangitis
BASIC INFORMATION
DEFINITION
Cholangitis refers to an inflammation and / or infection of the hepatic and common bile ducts associated with obstruction of the common bile duct.
SYNONYMS
Biliary sepsis
Ascending cholangitis
Suppurative cholangitis
SYMPTOMS
Pain, chills, and jaundice (Charcot triad) are the cardinal symptoms of cholangitis. Pain may be absent. Bacterial cholangitis especially in patients with extrahepatic bile duct obstruction by gallstones or strictures, is less frequent in tumor obstruction. Parasites rarely cause cholangitis.
Laboratory findings indicate cholestasis and a bacterial infection. Transaminase levels are only moderately raised. The liver is enlarged and painful upon palpation. Cholangitis resolves within a few days after antibiotic therapy, but recurs if the cause of the obstruction is not eliminated. Complications of cholangitis are liver abscess formation, sepsis, and secondary biliary cirrhosis in patients with a chronic clinical course.
BASIC INFORMATION
DEFINITION
Cholangitis refers to an inflammation and / or infection of the hepatic and common bile ducts associated with obstruction of the common bile duct.
SYNONYMS
Biliary sepsis
Ascending cholangitis
Suppurative cholangitis
SYMPTOMS
Pain, chills, and jaundice (Charcot triad) are the cardinal symptoms of cholangitis. Pain may be absent. Bacterial cholangitis especially in patients with extrahepatic bile duct obstruction by gallstones or strictures, is less frequent in tumor obstruction. Parasites rarely cause cholangitis.
Laboratory findings indicate cholestasis and a bacterial infection. Transaminase levels are only moderately raised. The liver is enlarged and painful upon palpation. Cholangitis resolves within a few days after antibiotic therapy, but recurs if the cause of the obstruction is not eliminated. Complications of cholangitis are liver abscess formation, sepsis, and secondary biliary cirrhosis in patients with a chronic clinical course.
EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE (IN U.S.): Complicates approximately 2% of cases of cholelithiasis
INCIDENCE (IN U.S.): Complicates approximately 2% of cases of cholelithiasis
• Other causes: prior biliary tract surgery with secondary stenosis, tumor (usually arising from the pancreas or biliary tree), and parasitic infections from Ascaris lumbricoides or Fasciola hepatica
• Iatrogenic after contamination of an obstructed biliary tree by endoscopic retrograde cholangiopancreatoscopy (ERCP) or percutaneous transhepatic cholangiography (PTC)
• Primary sclerosing cholangitis (PSC)
• HIV-Associated sclerosing cholangitis: associated with infection by CMV, Cryptosporidium, Microsporida, and Mycobacterium avium Complex
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Biliary colic
• Acute cholecystitis
• Liver abscess
• PUD
• Pancreatitis
• Intestinal obstruction
• Right kidney stone
• Hepatitis
• Pyelonephritis
WORKUP
• Blood cultures
• CBC
• Liver function tests
LABORATORY TESTS
• Usually, elevated WBC count with a predominance of polynuclear forms
• Elevated alkaline phosphatase and bilirubin in chronic obstruction
• Elevated transaminases in acute obstruction
• Positive blood cultures in 50% of cases, typically with enteric gram-negative aerobes (e.g., E. coli, klebsiella pneumoniae), enterococci, or anaerobes
IMAGING STUDIES
• Ultrasound:
1. Allows visualization of the gallbladder and bile ducts to differentiate extrahepatic obstruction from intrahepatic cholestasis
2. Insensitive but specific for visualization of common duct stones
• CT scan:
1. Less accurate for gallstones
2. More sensitive than ultrasound for visualization of the distal part of the common bile duct
3. Also allows better definition of neoplasm
• ERCP:
1. Confirms obstruction and its level
2. Allows collection of specimens for culture and cytology
3. Indicated for diagnosis if ultrasound and CT scan are inconclusive
4. May be indicated in therapy (see “Treatment”)
TREATMENT
NONPHARMACOLOGIC THERAPY
Biliary decompression
• May be urgent in severely ill patients or those unresponsive to medical therapy within 12 to 24 hours
• May also be performed semielectively in patients who respond
• Options:
1. ERCP with or without sphincter-otomy or placement of a draining stent
2. Percutaneous transhepatic biliary drainage for the acutely ill patient who is a poor surgical candidate
3. Surgical exploration of the common bile duct
ACUTE GENERAL Rx
• Nothing by mouth
• Intravenous hydration
• Broad-spectrum antibiotics directed at gram-negative enteric organisms, anaerobes, and enterococcus: if infection is nosocomial, post-ERCP, or the patient is in shock, strong consideration of broader coverage to include hospital organisms such as Pseudomonas aeruginosa, resistant Staphylococcus aureus, and others.
CHRONIC Rx
Repeated decompression may be necessary, particularly when obstruction is related to neoplasm.
DISPOSITION
Excellent prognosis if obstruction is amenable to definitive surgical therapy; otherwise relapses are common.
• Iatrogenic after contamination of an obstructed biliary tree by endoscopic retrograde cholangiopancreatoscopy (ERCP) or percutaneous transhepatic cholangiography (PTC)
• Primary sclerosing cholangitis (PSC)
• HIV-Associated sclerosing cholangitis: associated with infection by CMV, Cryptosporidium, Microsporida, and Mycobacterium avium Complex
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Biliary colic
• Acute cholecystitis
• Liver abscess
• PUD
• Pancreatitis
• Intestinal obstruction
• Right kidney stone
• Hepatitis
• Pyelonephritis
WORKUP
• Blood cultures
• CBC
• Liver function tests
LABORATORY TESTS
• Usually, elevated WBC count with a predominance of polynuclear forms
• Elevated alkaline phosphatase and bilirubin in chronic obstruction
• Elevated transaminases in acute obstruction
• Positive blood cultures in 50% of cases, typically with enteric gram-negative aerobes (e.g., E. coli, klebsiella pneumoniae), enterococci, or anaerobes
IMAGING STUDIES
• Ultrasound:
1. Allows visualization of the gallbladder and bile ducts to differentiate extrahepatic obstruction from intrahepatic cholestasis
2. Insensitive but specific for visualization of common duct stones
• CT scan:
1. Less accurate for gallstones
2. More sensitive than ultrasound for visualization of the distal part of the common bile duct
3. Also allows better definition of neoplasm
• ERCP:
1. Confirms obstruction and its level
2. Allows collection of specimens for culture and cytology
3. Indicated for diagnosis if ultrasound and CT scan are inconclusive
4. May be indicated in therapy (see “Treatment”)
TREATMENT
NONPHARMACOLOGIC THERAPY
Biliary decompression
• May be urgent in severely ill patients or those unresponsive to medical therapy within 12 to 24 hours
• May also be performed semielectively in patients who respond
• Options:
1. ERCP with or without sphincter-otomy or placement of a draining stent
2. Percutaneous transhepatic biliary drainage for the acutely ill patient who is a poor surgical candidate
3. Surgical exploration of the common bile duct
ACUTE GENERAL Rx
• Nothing by mouth
• Intravenous hydration
• Broad-spectrum antibiotics directed at gram-negative enteric organisms, anaerobes, and enterococcus: if infection is nosocomial, post-ERCP, or the patient is in shock, strong consideration of broader coverage to include hospital organisms such as Pseudomonas aeruginosa, resistant Staphylococcus aureus, and others.
CHRONIC Rx
Repeated decompression may be necessary, particularly when obstruction is related to neoplasm.
DISPOSITION
Excellent prognosis if obstruction is amenable to definitive surgical therapy; otherwise relapses are common.
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PREVALENCE (IN U.S.): 2 Cases / 1000 hospital admissions
PREDOMINANT SEX:
• Females, for cholangitis secondary to gallstones
• Males, for cholangitis secondary to malignant obstruction and HIV infection
PREDOMINANT AGE: Seventh decade and older; unusual < 50 years of age
PEAK INCIDENCE: Seventh decade
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Usually acute onset of fever, chills, abdominal pain, tenderness over the RUQ of the abdomen, and jaundice (charcot’s triad)
• All signs and symptoms in only 53% to 88% of patients
• Often, dark coloration of the urine resulting from bilirubinuria
• Complications:
1. Bacteremia (53%) and septic shock
2. Hepatic abscess and pancreatitis
ETIOLOGY
Obstruction of the common bile duct causing rapid proliferation of bacteria in the biliary tree
• Most common cause of common bile duct obstruction: stones, usually migrated from the gallbladder
PREDOMINANT SEX:
• Females, for cholangitis secondary to gallstones
• Males, for cholangitis secondary to malignant obstruction and HIV infection
PREDOMINANT AGE: Seventh decade and older; unusual < 50 years of age
PEAK INCIDENCE: Seventh decade
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Usually acute onset of fever, chills, abdominal pain, tenderness over the RUQ of the abdomen, and jaundice (charcot’s triad)
• All signs and symptoms in only 53% to 88% of patients
• Often, dark coloration of the urine resulting from bilirubinuria
• Complications:
1. Bacteremia (53%) and septic shock
2. Hepatic abscess and pancreatitis
ETIOLOGY
Obstruction of the common bile duct causing rapid proliferation of bacteria in the biliary tree
• Most common cause of common bile duct obstruction: stones, usually migrated from the gallbladder