GASTRO/GENSURG
CHOLANGITIS
PromptLFT’s (+ other investigations) in Cholangitis
ResponseConjugated hyperbilirubinemia - Jaundice due to biliary obstruction
Elevated membrane bound (cholestatic) LFT’s (ALP/GGT) - biliary obstruction
Less elevated/normal intracellular (hepatic) LFT’s (AST/ALT)
Protein high, albumin low, globulin high - Inflammatory state raised globulins to fight infection at expense of albumin production
HAGMA - renal failure
Hyponatraemia, hypochloraemia - GI losses
Renal failure
Lactate - sepsis/shock
Lipase ? pancreas
BSL
Elevated membrane bound (cholestatic) LFT’s (ALP/GGT) - biliary obstruction
Less elevated/normal intracellular (hepatic) LFT’s (AST/ALT)
Protein high, albumin low, globulin high - Inflammatory state raised globulins to fight infection at expense of albumin production
HAGMA - renal failure
Hyponatraemia, hypochloraemia - GI losses
Renal failure
Lactate - sepsis/shock
Lipase ? pancreas
BSL
PromptImaging for cholangitis available to ED - Pros + Cons
ResponseCT
Pros - Specifica and sensitive for CBD dilation/obstruction/cause/level (Cholangitis)
Good sensitivity for cholecystitis (wall thickening, pericholecystic fluid). Can also assess pancreas if obstruction. Assess for other pathology (intraabdominal, renal, pneumonia)
Cons - not as sensitive for gallstones as US, Contrast (allergy, nephropathy), Radiation
US
Pros - Sensitive and specific for gallstones and cholecystitis (Inv of choice), Sensitive for biliary duct dilation (Cholangitis)
Cons - May not define level/cause of obstruction if ductal lesion/cholangitis, especially if distal. Limited diagnosis of other intraabdominal pathology. Operator/body habitus dependent.
Pros - Specifica and sensitive for CBD dilation/obstruction/cause/level (Cholangitis)
Good sensitivity for cholecystitis (wall thickening, pericholecystic fluid). Can also assess pancreas if obstruction. Assess for other pathology (intraabdominal, renal, pneumonia)
Cons - not as sensitive for gallstones as US, Contrast (allergy, nephropathy), Radiation
US
Pros - Sensitive and specific for gallstones and cholecystitis (Inv of choice), Sensitive for biliary duct dilation (Cholangitis)
Cons - May not define level/cause of obstruction if ductal lesion/cholangitis, especially if distal. Limited diagnosis of other intraabdominal pathology. Operator/body habitus dependent.
PromptManagement of Ascending Cholangitis
ResponseIV fluids 20 mL/kg N/S aiming MAP >65 or systolic >100, Urine >0.5mL/kg/hr
Analgesia with fentanyl 25mics repeat to comfort
Antibiotics eTG Oct 24:
Amp + Gent (Taz if gent contraindicated, Ceftriaxone/cefotaxime if penicillin allergy)
Surgeons or interventional gastroenterology for ERCP/laparotomy (Site/availability dependent)
Analgesia with fentanyl 25mics repeat to comfort
Antibiotics eTG Oct 24:
Amp + Gent (Taz if gent contraindicated, Ceftriaxone/cefotaxime if penicillin allergy)
Surgeons or interventional gastroenterology for ERCP/laparotomy (Site/availability dependent)
Charcot’s triad - Fever, RUQ pain, Jaundice
Reynolds Pentad - Fever, RUQ pain, Jaundice, Sepsis/shock, altered mental state