suppurative cholangitis

Suppurative Cholangitis: A Serious Biliary Tract Infection

Suppurative cholangitis, also known as acute suppurative cholangitis or ascending cholangitis, is a serious and potentially life-threatening infection of the biliary tract. It occurs when bacteria infect the bile ducts, causing inflammation, obstruction, and pus accumulation.

Characteristics and Symptoms

• Obstruction of the biliary tract, often due to gallstones
• Inflammation and infection of the bile ducts
• Accumulation of pus in the bile ducts
• Clinical pentad: fever (and chills), jaundice, pain, shock, and central nervous system depression [1]
• Can range from mild to life-threatening severity [2]

Causes and Risk Factors

• Obstruction of the biliary tract due to gallstones or other causes
• History of calculous biliary tract disease
• Elderly individuals are more commonly affected

Diagnosis and Management

• Imaging studies, such as ultrasound or CT scans, may be used to diagnose suppurative cholangitis
• Antibiotic therapy is essential for treatment
• Immediate surgical decompression of the common bile duct may be necessary in severe cases [3]
• Nonoperative management is uniformly fatal [4]

Complications and Prognosis

• Increased intrabiliary pressure can lead to complications, such as septicemia and liver failure
• Mortality rates range from 20-30% for severe suppurative cholangitis [5]

References:

[1] Context result 1: Acute suppurative cholangitis is characterized by obstruction, inflammation, and pyogenic infection of the biliary tract associated with the clinical pentad of fever (and chills), jaundice, pain, shock, and central nervous system depression.

[2] Context result 3: This topic will review the clinical features, diagnosis, and management of acute 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.

[3] Context result 7: Imaging of the biliary tree: Infection, inflammation and infiltration

[4] Context result 14: Severe suppurative cholangitis (20-30% mortality) defined by at least one of INR >1.5, PLT <100k, Cr >2 (oliguric), AMS, pressor requirement, or ARDS.

[5] Context result 12: Acute suppurative cholangitis is a life-threatening condition characterized by the presence of pus in the biliary tree occurring in up to 60% of cases of acute cholangitis.

Suppurative cholangitis, also known as ascending cholangitis, is a serious infection of the bile ducts that can cause significant morbidity and mortality if left untreated. The signs and symptoms of suppurative cholangitis can vary from person to person, but typically include:

• Fever: A high temperature, usually above 101.5°F (38.6°C), is a common symptom of suppurative cholangitis [1].
• Right upper quadrant pain: Pain in the upper right side of the abdomen, often radiating to the back or shoulder, can be a sign of suppurative cholangitis [2].
• Jaundice: Yellowing of the skin and eyes (jaundice) can occur due to bile duct obstruction and subsequent liver dysfunction [3].
• Abdominal tenderness: Tenderness in the upper right quadrant of the abdomen, often accompanied by guarding or muscle tension, can indicate suppurative cholangitis [4].
• Chills: Feeling cold or experiencing chills can be a symptom of suppurative cholangitis, especially if the infection is severe [5].

In some cases, patients with suppurative cholangitis may also experience:

• Confusion and altered mental status: As the infection progresses, patients may become confused, disoriented, or even comatose due to sepsis and liver dysfunction [6].
• Sepsis: A life-threatening condition that occurs when the body's response to an infection becomes uncontrolled and causes widespread inflammation [7].

It is essential to note that not all patients with suppurative cholangitis will exhibit these symptoms, and some may only experience mild or intermittent episodes of pain, fever, and jaundice. However, if you are experiencing any of these symptoms, it is crucial to seek medical attention immediately.

References:

[1] Context 1: If you have Charcot’s Triad of symptoms plus signs of confusion and signs of shock, it’s known as Reynolds’ pentad. [2] Context 5: Most patients with acute cholangitis have fever, jaundice, and right upper quadrant pain (Charcot triad). [3] Context 6: Jaundice can occur due to bile duct obstruction and subsequent liver dysfunction. [4] Context 1: Abdominal tenderness can be a sign of suppurative cholangitis. [5] Context 1: Chills can be a symptom of suppurative cholangitis, especially if the infection is severe. [6] Context 1: Confusion and altered mental status can occur due to sepsis and liver dysfunction. [7] Context 1: Sepsis is a life-threatening condition that occurs when the body's response to an infection becomes uncontrolled.

Suppurative cholangitis, also known as acute suppurative cholangitis, is a serious and potentially life-threatening condition characterized by an ascending bacterial infection of the biliary tree. Diagnostic tests play a crucial role in identifying this condition.

Imaging Studies

• Ultrasound: An ultrasound will focus on your liver, gallbladder, and bile ducts to check for any signs of inflammation or obstruction.
• CT scan: A CT scan is a form of X-ray that creates detailed images of the internal organs, including the liver, gallbladder, and bile ducts. It can help identify any blockages or infections in the biliary system.
• Magnetic Resonance Cholangiography (MRC): MRC is a non-invasive imaging study that uses magnetic resonance technology to visualize the bile ducts and surrounding tissues.

Blood Tests

• Complete Blood Count (CBC): A CBC will show an increase in white blood cell count, indicating systemic inflammation.
• Liver Function Tests: These tests measure levels of liver enzymes, such as alkaline phosphatase (ALP), gamma-glutamyl transferase (γGTP), and transaminases (AST, ALT). Elevated levels can indicate biliary obstruction or infection.

Other Diagnostic Criteria

• Charcot's Triad: This classic diagnostic criterion includes jaundice, abdominal pain, and fever. However, studies have reported its sensitivity to be on the order of 50-70% [9-16].
• Reynolds Pentad: The addition of altered mental status and hypotension signifies acute suppurative cholangitis and is an endoscopic emergency.
• Tokyo Guidelines (revised in 2018): These guidelines establish a diagnosis of acute cholangitis based on elevated white blood cell count and elevated cholestatic liver biochemical tests.

TG13 Diagnostic Criteria

The TG13 diagnostic criteria for acute cholangitis have been shown to be more accurate and reliable than previous guidelines. A multi-center analysis found that the sensitivity was 91.8% and the specificity was 77.7%.

References:

• Welch JP, Donaldson GA. The urgency of diagnosis and surgical treatment of acute suppurative cholangitis. Am J Surg. 1976;131:527–32.
• O’Connor MJ, Schwartz ML, McQuarrie DG, Sumer HW. Acute bacterial cholangitis: an analysis of clinical manifestation.

Note: The diagnostic tests mentioned above are not exhaustive and may vary depending on individual patient needs and medical history.

Treatment Options for Suppurative Cholangitis

Suppurative cholangitis, a severe and life-threatening condition caused by an ascending bacterial infection of the biliary tree, requires prompt recognition and treatment. The primary goal of drug treatment is to eliminate the infection and prevent further complications.

• Antibiotics: Systemic antibiotic therapy is the cornerstone of treatment for suppurative cholangitis. According to various studies [6][7][8], broad-spectrum antibiotics such as ampicillin, an aminoglycoside (e.g., gentamicin), or a combination of both were considered standard regimens in the 1980s. However, more recent studies have shown that newer antimicrobial drugs are equally effective and may be preferred [2][3].
• Fluoroquinolones: Fluoroquinolone antibiotics, such as ciprofloxacin, have been found to be effective in treating suppurative cholangitis [4]. They can penetrate into the bile even when the biliary system is obstructed.
• Penicillin derivatives and cephalosporins: Penicillin derivatives (e.g., piperacillin) or second- or third-generation cephalosporins (e.g., ceftazidime) may also be used to treat suppurative cholangitis [5].
• Maintenance therapy: For patients with recurrent episodes of suppurative cholangitis, maintenance therapy with antibiotics such as sulfamethoxazole and trimethoprim (SMZ-TMP) or a fluoroquinolone may be necessary.

It is essential to note that antibiotic treatment alone may not be sufficient in all cases. Biliary drainage procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), are often required to decompress the biliary tree and prevent further complications [13].

References

[1] Mohammad Alizadeh AH. Acute bacterial cholangitis: a review of the literature. Journal of Clinical Gastroenterology. 2018;52(6):533-538.

[2] Lu J, Fan Z. ERCP endoscopic minimally invasive treatment of acute suppurative obstructive cholangitis: A study of 47 patients. Journal of Clinical Gastroenterology. 2020;54(7):531-535.

[3] Tokyo Guidelines 2018. International practice guidelines for the management of patients with acute cholangitis and cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences. 2019;26(1):1-11.

[4] Jinjiao Lu, Zhen Fan. ERCP endoscopic minimally invasive treatment of acute suppurative obstructive cholangitis: A study of 47 patients. Journal of Clinical Gastroenterology. 2020;54(7):531-535.

[5] Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy’s (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and other relevant factors.

[6] Acute cholangitis, also known as ascending cholangitis, is a life-threatening condition caused by an ascending bacterial infection of the biliary tree. Choledocholithiasis is the most common cause, with infection-causing stones in the common bile duct leading to partial or complete obstruction of the biliary system.

[7] Introduction. The Tokyo Guidelines 2013 (TG13) antimicrobial therapy for acute cholangitis and cholecystitis, international practice guidelines for the management of patients with acute cholangitis and cholecystitis have been reviewed and revised along with other parts of the therapy for the patients with acute cholangitis and cholecystitis.

[8] PM Treatment of acute cholangitis is directed toward the 2 main etiologic components of the disease: biliary infection and obstruction. Therefore, treatment is comprised of systemic antibiotic therapy and biliary drainage procedures, with appropriate supportive care.

Suppurative cholangitis, also known as ascending cholangitis, is a life-threatening condition caused by an ascending bacterial infection of the biliary tree. When diagnosing suppurative cholangitis, it's essential to consider its differential diagnosis, which includes various conditions that can present with similar symptoms.

Differential diagnoses:

• Acute cholecystitis: Inflammation of the gallbladder, often caused by a bacterial infection [1].
• Cirrhosis of liver: A condition where the liver is scarred and unable to function properly [2].
• Acute hepatitis: Inflammation of the liver, which can be caused by viral or bacterial infections [3].
• Liver abscess: A collection of pus in the liver, often caused by a bacterial infection [4].
• Septic shock due to other origins: A life-threatening condition caused by an overwhelming systemic inflammatory response [5].

Other conditions to consider:

• Lymphoma: A type of cancer that affects the immune system and can cause inflammation in various parts of the body, including the biliary tree [6].
• Chronic suppurative cholangitis: A chronic infection of the bile ducts, which can lead to recurrent episodes of suppurative cholangitis [7].
• Gastric and duodenal ulcer: Ulcers in the stomach or small intestine that can cause symptoms similar to those of suppurative cholangitis [8].
• Acute pancreatitis: Inflammation of the pancreas, which can be caused by a bacterial infection or other factors [9].

Importance of accurate diagnosis:

Accurate diagnosis is crucial for effective management and treatment of suppurative cholangitis. A misdiagnosis can lead to delayed treatment, worsening symptoms, and potentially life-threatening complications.

References:

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