The predominant organisms in bile in approximately decreasing frequency are E coli, Klebsiella, Pseudomonas, Enterococci, and Proteus. 

Bacteroides fragilis and other anaerobes (eg, Clostridium perfringens) can be detected in about 25% of cases.

Anaerobes are nearly always seen in the company of aerobes.

 

 

This occurs due to common duct obstruction, most commonly from a gallstone. Complications include obstruction, jaundice, fever, leukocytosis, sepsis, and pancreatitis.

[ERCP is both diagnostic and therapeutic. It is the preferred test of choice in patients with a high pretest probability of CBD stone with obstruction. It allows direct cannulation of CBD and relieves obstruction via simultaneous stone extraction and sphincterotomy. In patients who are less likely to have a CBD stone, a less invasive test such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would be appropriate as an initial study. Treatment includes IV hydration, IV broad-spectrum antibiotics, decompression of the biliary system (via ERCP in patients with persistent pain, hypotension, altered mental status, persistent high fever, WBC ≥20,000, bilirubin >10 mg/dL) and electively in more stable patients, and/or cholecystectomy.

Blood cultures are frequently positive, and leukocytosis is typical. Nonsuppurative acute cholangitis is most common and may respond relatively rapidly to supportive measures and to treatment with antibiotics. In suppurative acute cholangitis, however, the presence of pus under pressure in a completely obstructed ductal system leads to symptoms of severe toxicity—mental confusion, bacteremia, and septic shock. Response to antibiotics alone in this setting is relatively poor, multiple hepatic abscesses are often present, and the mortality rate approaches 100% unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out. Endoscopic management of bacterial cholangitis is as effective as surgical intervention. ERCP with endoscopic sphincterotomy is safe and the preferred initial procedure for both establishing a definitive diagnosis and providing effective therapy.

Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract.

It is also referred to as ascending cholangitis. Cholangitis was first described by Charcot as a serious and life-threatening illness; however, it is now recognized that the severity can range from mild to life-threatening [1].

 

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Treatment includes IV hydration

, IV broad-spectrum antibiotics,

decompression of the biliary system (via ERCP in patients with persistent pain, hypotension, altered mental status, persistent high fever, WBC ≥20,000, bilirubin >10 mg/dL)

[and electively in more stable patients, and/or cholecystectomy.]

Endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out.

In suppurative acute cholangitis, however, the presence of pus under pressure in a completely obstructed ductal system leads to symptoms of severe toxicity—mental confusion, bacteremia, and septic shock. Response to antibiotics alone in this setting is relatively poor, multiple hepatic abscesses are often present, and the mortality rate approaches 100% unless prompt endoscopic or surgical relief of the obstruction and drainage of infected bile are carried out. Endoscopic management of bacterial cholangitis is as effective as surgical intervention. ERCP with endoscopic sphincterotomy is safe and the preferred initial procedure for both establishing a definitive diagnosis and providing effective therapy.

 

Most cases of cholangitis can be controlled with intravenous antibiotics. A cephalosporin antibiotic (eg, cefazolin, cefoxitin) is the drug of choice in the average mild to moderately severe case. If disease is severe or progressively worsens, an aminoglycoside plus clindamycin or metronidazole should be added to the regimen.

For patients with severe cholangitis or unremitting cholangitis despite antibiotic therapy, the bile duct must be promptly decompressed. Most cases of severe acute cholangitis are associated with choledocholithiasis, for which the best treatment consists of emergency endoscopic sphincterotomy. In the uncommon case where this is unsuccessful, laparotomy is indicated in order to decompress the bile duct. Cholangitis accompanying neoplastic obstruction may be managed by insertion of a transhepatic drainage catheter into the bile duct. A cholangiogram should not be obtained because the procedure could worsen sepsis.

Urgent intervention (eg, endoscopic sphincterotomy, percutaneous transhepatic drainage, or operative decompression) is required in about 10% of patients with acute cholangitis. The remaining 90% are eventually treated by elective surgery or endoscopic sphincterotomy following antibiotic therapy and a thorough diagnostic evaluation.

 

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Complications include obstruction, jaundice, fever, leukocytosis, sepsis, and pancreatitis.

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Question 1 of 1

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?

Answer

 

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