Ascending cholangitis

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Ascending cholangitis


Peritoneum and peritoneal cavity disorders




Ascending cholangitis


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Ascending cholangitis

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A 55-year-old woman is brought to the emergency department due to progressive upper abdominal pain and fever for the past 2 days. She states she has felt persistently nauseous over this time period and has vomited 5 times. Medical history is noncontributory. Temperature is 38.6°C (101.4°F), pulse is 80/min, and blood pressure is 135/85 mmHg. Examination reveals a patient in acute distress. Physical examination reveals yellow discoloration of the sclera. The abdomen is tender to palpation in the right upper quadrant. There is no rebound tenderness. No hepatomegaly is observed. Laboratory studies show the following:  
 Laboratory value  Result 
 Hemoglobin  14 g/dL 
 Leukocyte count  17,000 mm3 
 Platelet count    240,000 mm3 
 Mean corpuscular volume  87 μm3 
 Creatinine   0.8 g/dL 
 BUN  12 mg/dL 
 Total   3.8 mg/dL 
 Direct  2.5 mg/dL 
 Alanine aminotransferase   190 U/L 
 Aspartate aminotransferase  210 U/L 
 Amylase  57 U/L 
 Lipase  65 U/L 
 Alkaline phosphatase   412 U/L 

Abdominal ultrasound shows dilation of the intra- and extrahepatic ducts. IV fluids and antibiotics are administered. Six hours later, the patient becomes disoriented. Temperature is 38.6°C (101.4°F), pulse is 101/min, and blood pressure is 95/60 mmHg. Which of the following is the most likely cause of this patient’s presentation?  

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Ascending cholangitis p. 406


Content Reviewers

With ascending cholangitis, “cholang-” refers to the bile ducts and “-itis” refers to inflammation which is usually caused by a bacterial infection.

These bacteria are normally found in the intestines and work their way up the bile ducts from the duodenum of the small intestine, so that’s why it’s known as ascending cholangitis, also sometimes acute cholangitis because it can happen over a relatively short period of time.

Normally bacteria from the gut has a pretty tough time ascending up the bile ducts, and this is because bile flows down from the gallbladder, along with some pancreatic juice from the pancreas, into the duodenum, and this tends to flush out any bacteria trying to sneak their way up.

In ascending cholangitis this flow of bile is often blocked, and one common reason is choledocholithiasis, which refers to gallstones in the common bile duct.

In choledocholithiasis, gallstones form in the gallbladder and occasionally slip out, travel through the cystic bile duct, and then lodge into the common bile duct, obstructing the normal flow of bile.

These gallstones are typically made up of bile components, and risk factors for developing them include things like female sex, obesity, pregnancy, and age, sometimes remembered by the 4 F’s—female, fat, fertile, and forty. Other, less common causes include things that cause stricture, or narrowing of the bile ducts—like a nearby cancerous growth, which can compress the duct as the tumor slowly enlarges, or injury experienced during a laparoscopic procedure.

Once the flow of bile is blocked, bacteria can slowly make their way up the ducts and colonize the biliary system without the risk of being washed away.

Most commonly the bacterial species involved are a mixture of enteric organisms including common ones like E coli, Klebsiella species, and Enterococcus species.


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