Choledocholithiasis & Acute Cholangitis
Etiology and Pathology
Choledocholithiasis: stone in common bile duct (CBD)
Stone usually originates in gallbladder then travels
Stones increase risk of obstruction of hepatobiliary tree and pancreatic ducts
Cholangitis: inflammation and/or infection of common bile duct (CBD)
Related to obstruction caused by choledocholithiasis
Obstruction lasting over 30 days can cause liver damage
Clinical Manifestations
Initial symptoms same as “simple” biliary disease
Biliary colic/RUQ pain
Boas sign
Acute cholecystitis
Murphy’s sign (+)
Charcot’s Triad
Biliary pain
Fever/chills
Jaundice
Reynold’s Pentad – Charcot’s Triad PLUS
Altered mental status
Hypotension
PE: hepatomegaly, tender RUQ/epigastrum
Diagnosis/Work-Up
Laboratory
↑ AST, ALT, bilirubin, Alk Phos
↑ amylase/lipase
↑ WBC (if cholangitis)
Imaging
Endoscopic retrograde cholangiopancreatography (ERCP)
Diagnostic and therapeutic
Ultrasound or CT
Dilation of CBD seen
Tokyo Guidelines: utilized to help diagnose acute cholangitis
Presence of Charcot’s Triad OR
Presence of 2 elements of Charcots Triad PLUS one of the following:
Inflammation
↑ LFTs
Biliary dilation on imaging
Differential Diagnosis
Neoplasia or tumor
Chronic cholestasis
Treatment
Therapeutic ERCP
Laparoscopic cholecystectomy
Hospitalization
NPO
IV fluids
Empiric antibiotics