Upward cholangitis , also known as acute cholangitis or just cholangitis , is a bile duct infection (cholangitis), usually caused by bacteria rising from the junction with the duodenum (the first part of the small intestine). This tends to occur if the bile ducts have been partially blocked by gallstones.
Cholangitis can be life-threatening, and is considered a medical emergency. The characteristic symptoms include yellow discoloration of the skin or whites of the eyes, fever, abdominal pain, and in severe cases, low blood pressure and confusion. Initial treatment is with intravenous fluids and antibiotics, but there are often fundamental problems (such as gallstones or narrowing in the bile duct) that require further testing and treatment, usually in the form of endoscopy to reduce bile duct obstruction.. The word comes from the Greek chol -, bile ang -, blood vessels - itis , inflammation.
Video Ascending cholangitis
Signs and symptoms
A person with cholangitis may complain of abdominal pain (especially in the right upper quadrant of the abdomen), fever, stiffness (shaking uncontrollably) and anxiety (malaise). Some may report jaundice (yellow discoloration of the skin and whites of the eyes).
Physical examination findings usually include jaundice and upper right quadrant pain. Triad Charcot is a set of three common findings on cholangitis: abdominal pain, jaundice, and fever. It is assumed in the past to be present in 50-70% of cases, although recently the frequency has been reported as 15-20%. Pentad Reynolds includes Charcot's triad findings in the presence of septic shock and mental confusion. The combination of these symptoms indicates a worsening of the condition and development of sepsis, and appears less common.
In the elderly, presentations may be unusual; they can collapse immediately because of sepsis without showing typical features. Those who have a stent dwell in the bile ducts (see below) may not have jaundice.
Maps Ascending cholangitis
Cause
Bile duct obstruction, which usually occurs in acute cholangitis, is commonly caused by gallstones. 10-30% of cases, however, are due to other causes such as benign sterilization (narrowing of the bile ducts without underlying tumors), postoperative damage or altered structures of the bile ducts such as narrowing in place of anastomosis (surgical connection), various tumors (cancer of the canal bile, gall bladder cancer, Vater's ampullary cancer, pancreatic cancer, duodenal cancer), anaerobic organisms such as Clostridium and Bacteroides (especially in the elderly and those who have previously experienced bile duct surgery). Parasites that can infect the liver and bile ducts can cause cholangitis; this includes the Ascaris lumbricoides roundworm and cleaved cleansing of Clonorchis sinensis, Opisthorchis viverrini and Opisthorchis felineus. . In people with AIDS, a large number of opportunistic organisms have been known to cause AIDS cholangiopathy, but the risk has diminished rapidly since the introduction of effective AIDS treatment. Cholangitis can also complicate medical procedures involving the bile ducts, especially ERCP. To prevent this, it is recommended that those undergoing ERCP for any indication receive prophylactic antibiotics (prevention).
The presence of a permanent biliary stent (eg in pancreatic cancer) slightly increases the risk of cholangitis, but this type of stent is often necessary to keep bile patina ducts under external pressure.
Pathogenesis
Bile is produced by the liver, and serves to remove cholesterol and bilirubin from the body, as well as fat emulsifiers to make them more soluble in water and help their digestion. Bile is formed in the liver by hepatocytes (liver cells) and is secreted into the general liver duct. Part of the bile is stored in the gallbladder due to back pressure (given by the Oddi sphincter), and may be released at the time of digestion. The gallbladder also concentrates bile by absorbing water and dissolved salts from it. All bile reaches the duodenum (first part of the small intestine) through the bile duct and the Vater ampule. The Oddi sphincter, located at the intersection of Vater's ampoule and duodenum, is a circular muscle that controls the release of both secretion of bile and pancreas into the gastrointestinal tract.
The biliary tree is usually relatively free from bacteria due to certain protection mechanisms. Oddter Oddi acts as a mechanical barrier. The bile system usually has a low pressure (8 to 12 cmH 2 O) and allows free flowing bile. The continuous forward flow of bile in the bacterial flushes channels, if present, to the duodenum, and does not allow the formation of infection. Constitution of biliary bile salts and immunoglobulins secreted by the epithelial bile duct also have a protective role.
Bacterial contamination alone in the absence of obstruction usually does not cause cholangitis. But an increase in pressure in the bile system (above 20 cmH 2 O) resulting from obstruction in the bile ducts widens space between cells lining the ducts, carrying bacterial contaminated bile in contact with bloodstream. It also affects the function of Kupffer cells, which are specialized macrophage cells that help prevent bacteria from entering the bile system. Finally, increased biliary pressure decreases the production of IgA immunoglobulin in the bile. This causes bacteremia (bacteria in the bloodstream) and causes systemic inflammatory response syndrome (SIRS) consisting of fever (often accompanied by hardness), tachycardia, increased respiratory rate and increased white blood cell count; SIRS in the presence of a suspected or confirmed infection is called sepsis. Biliary obstruction itself is detrimental to the immune system and damages its ability to fight infections, by damaging the function of certain immune system cells (granulocytes neutrophils) and modifying levels of the immune hormone (cytokines).
In ascending cholangitis, it is assumed that the organism migrates behind the bile ducts as a result of partial obstruction and decreased function of the Oddi sphincter. Other theories about bacterial origin, such as through the portal vein or transmigration of the colon, are considered less likely.
Diagnosis
Blood tests
Regular blood tests show a picture of acute inflammation (increased white blood cell count and elevated levels of C-reactive protein), and usually abnormal liver function tests (LFTs). In many cases, LFTs will be consistent with obstruction: increased bilirubin, alkaline phosphatase and? -glutamyl transpeptidase. In the early stages, pressure on liver cells may be a major feature and tests will resemble hepatitis, with elevated alanine transaminases and aspartate transaminases.
Blood cultures are often performed in patients with fever and evidence of acute infection. It produces bacteria that cause infection in 36% of cases, usually after 24-48 hours of incubation. Gall can also be sent for culture during ERCP (see below). The most common bacteria associated with elevated cholangitis are gram-negative bacilli: Escherichia coli (25-50%), Klebsiella (15-20%) and Enterobacter (5-10%). Of the gram positive cocci, Enterococcus causes 10-20%.
Medical description
Given ascending cholangitis usually occurs in the regulation of bile duct obstruction, various forms of medical imaging can be used to identify the site and nature of this obstruction. The first investigation is usually ultrasound, as this is the most readily available. Ultrasound may show dilatation of the bile ducts and identify 38% of the bile duct stones; it is relatively poor in identifying rocks deep beneath the bile ducts. Ultrasound can help distinguish between cholangitis and cholecystitis (inflammation of the gallbladder), which has symptoms similar to cholangitis but appears different on ultrasound. Better tests are magnetic resonance cholangiopancreatography (MRCP), which uses magnetic resonance imaging (MRI); it has a sensitivity comparable to ERCP. However, smaller stones can still be passed on MRCP depending on the quality of hospital facilities.
The standard gold test for biliary obstruction is still cholangopancreatographic retrograde endoscopy (ERCP). This involves the use of endoscopy (passing the tube through the mouth to the esophagus, the stomach and then to the duodenum) to pass the small cannula into the bile ducts. At that time, the radiocontrast is injected to obscure the duct, and the X-rays are taken to get a visual impression of the biliary system. In amphetical endoscopic images, one can sometimes see protuberant ampulls of affected gallstones in the common bile ducts or extrusion of pus from the common bile ducts. In the X-ray image (known as cholangiogram), gallstones are seen as non-opacified areas in duct contours. For diagnostic purposes, ERCP has now been largely superseded by MRCP. ERCP is only used first-line in critically ill patients including delay for unacceptable diagnostic tests; However, if the index of suspicion for cholangitis is high, ERCP is usually performed to achieve unobstructed bile duct drainage.
If other causes of gallstones are suspected (such as tumors), computed tomography and endoscopic ultrasound (EUS) may be performed to identify the nature of the obstruction. EUS can be used to obtain biopsy (tissue samples) from suspicious masses. EUS can also replace ERCP diagnostics for stone diseases, although this depends on local availability.
Treatment
Liquid and antibiotics
Cholangitis requires hospitalization. Intravenous fluids are given, especially if the blood pressure is low, and antibiotics begin. Empirical treatment with broad-spectrum antibiotics is usually necessary until it is known which pathogens cause infection, and which antibiotics are sensitive. Penicillin and aminoglycoside combinations are widely used, although ciprofloxacin has proven to be effective in many cases, and may be preferred for aminoglycosides because of fewer side effects. Metronidazole is often added to specifically treat anaerobic pathogens, especially in those who are very sick or at risk of developing anaerobic infection. Antibiotics are continued for 7-10 days. Drugs that increase blood pressure (vasopressor) may also be needed to fight low blood pressure.
Endoscopy
The definitive treatment for cholangitis is to remove the underlying biliary obstruction. This is usually delayed up to 24-48 hours after admission, when the patient is stable and has shown some improvement with antibiotics, but may need to occur as an emergency in case of continuous damage despite adequate treatment, or if antibiotics are not effective in reducing signs of infection (which occurs in 15% of cases).
Endoscopic retrograde cholangiopancreatography (ERCP) is the most common approach in unblocking the bile ducts. This involves endoscopy (passing the fiber-optic tube through the stomach to the duodenum), identifying the Vater ampoule and inserting a small tube into the bile ducts. Sphincterotomy (making an incision in the Oddi sphincter) is usually done to facilitate the flow of bile from the ducts and allows the insertion of instruments to extract the gallstones that block the bile ducts; alternatively or additionally, a common bile duct hole may be dilated with a balloon. Stones can be removed either by direct suction or by using a variety of instruments, including balloons and baskets to crawl the bile ducts to attract the stone to the duodenum. Barriers caused by larger stones may require the use of an instrument known as a mechanical lithotriptor to destroy stones before disposal. Blocking stones that are too large to be disposed or mechanically damaged by ERCP can be managed by extracorporeal shock wave lithotripsy. This technique uses an acoustic shock wave given outside the body to break the stone. An alternative technique for removing very large inhibitors is electrohydraulic lithotripsy, where a small endoscope known as a cholangioscope is inserted by ERCP to visualize the stone directly. A probe uses electricity to produce shock waves that break down blocking stones. Rarely, surgical exploration of the bile ducts (called choledochotomy), which can be done with laparoscopy, is necessary to remove the stone.
The narrowed area may be bridged by a stent, vacuum tube that keeps the channel open. Detachable plastic stents are used in uncomplicated gallstone disease, while permanently extended metal stents with longer lifespan are used if the obstruction occurs due to pressure from a tumor such as pancreatic cancer. Nasobiliary channels may be missed; this is a plastic tube that escapes from the bile ducts through the stomach and nose and allows the continuous drainage of bile into a receptor. This is similar to a nasogastric tube, but goes into the common bile ducts directly, and allows for serial X-ray cholangiograms to be performed to identify increased obstruction. Which decisions of the treatments mentioned above are generally based on the severity of the obstruction, findings on other imaging studies, and whether the patient has improved with antibiotic treatment. Certain treatments may be unsafe if blood clots are impaired, because the risk of bleeding (especially from sphincterotomy) increases in drug use such as clopidogrel (which inhibits platelet aggregation) or if prothrombin time is significantly prolonged. For prolonged prothrombin time, vitamin K or fresh frozen plasma may be given to reduce the risk of bleeding.
Percutaneous barium drainage
In cases where a person is too ill to tolerate endoscopy or when a retrograde endoscopic approach fails to access the obstruction, a percutaneous percutaneous cholangiogram (PTC) can be performed to evaluate the biliary system for percutaneous bile duct deposition (PBD). This is often necessary in cases of proximal strictures or bilioenteric anastomoses (surgical connections between the bile ducts and the small intestine, such as the duodenum or jejunum). Once access across the stricture is obtained, the balloon widening can be performed and the stone can be swept into the duodenum. Due to the potential complications of percutaneous bile duct deposition and the need for regular line maintenance, retrograde approach through ERCP remains first-line therapy.
Cholecystectomy
Not all gallstones involved in cholangitis actually originate from the gallbladder, but cholecystectomy (surgical removal of the gallbladder) is generally recommended in people who have been treated for cholangitis due to gallstone disease. This is usually delayed until all symptoms have been resolved and ERCP or MRCP has confirmed that the bile ducts are clear of gallstones. Those who did not undergo cholecystectomy had an increased risk of recurrent biliary pain, jaundice, further episodes of cholangitis, and the need for further ERCP or cholecystostomy; the risk of death also increased significantly.
Prognosis
Acute cholangitis has a significant risk of death, the main cause is irreversible shock with multiple organ failure (possibly severe infection complications). Improvements in diagnosis and treatment have led to a decline in mortality: before 1980, mortality rates were greater than 50%, but after 1980 was 10-30%. Patients with multiple organ failure signs are likely to die unless they undergo early biliary drainage and treatment with systemic antibiotics. Other causes of death after severe cholangitis include heart failure and pneumonia.
Risk factors that show an increased risk of death include older age, female gender, history of cirrhosis of the liver, bile narrowing due to cancer, acute renal failure and liver abscess. Complications after severe cholangitis include renal failure, respiratory failure (inability of the respiratory system to oxygenate blood and/or eliminate carbon dioxide), cardiac arrhythmia, wound infection, pneumonia, gastrointestinal bleeding and myocardial ischemia (lack of blood flow to the heart, causing for heart attack).
Epidemiology
In the Western world, about 15% of all people have gallstones in their gallbladder but the majority are unaware of this and have no symptoms. Over ten years, 15-26% will suffer one or more biliary colic episodes (abdominal pain due to the passage of gallstones through the bile ducts to the gastrointestinal tract), and 2-3% will develop complications of obstruction: acute pancreatitis, cholecystitis or acute cholangitis. The prevalence of gallstone disease increases with age and body mass index (markers of obesity). However, the risk is also increased in those who lose weight quickly (eg after weight loss surgery) due to changes in the composition of the bile that makes it vulnerable to form stones. Gallstones are slightly more common in women than in men, and pregnancy increases risk further.
History
Dr Jean-Martin Charcot, working at the SalpÃÆ'ªtriÃÆ'¨re Hospital in Paris, France, is credited with an early report of cholangitis, as well as his eponymous triad, in 1877. He referred to this condition as "liver fever" ( fiÃÆ'¨vre hÃre  © patique ). Dr. Benedict M. Reynolds, an American surgeon, rekindled his interest in the conditions in the 1959 report with his colleague Dr. Everett L. Dargan, and formulated a pentad that carries his name. This remains a condition commonly treated by surgeons, with bile duct explorations and gallstone excision, until the rise of ERCP in 1968. ERCP is generally performed by specialist internal medicine or gastroenterology. In 1992 it was shown that ERCP was generally safer than surgical intervention in ascending cholangitis.
See also
- Primary sclerosing cholangitis (an autoimmune disease that causes biliary tract constriction)
- Gallstick related pancreatitis
References
External links
Source of the article : Wikipedia
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