Emergency General Surgery

The Strange Story of Salmons Swimming Upstream

Remember, a dead fish can float downstream, but it takes a live one to swim upstream.

W.C.Fields

Hello there…

As always, we are back with something new to talk about…

In our previous posts, we have already explored the mysteries lying behind acute cholecystitis and acute pancreatitis… However, something is missing in between…

So then, prepare yourself and come with us into the world of acute cholangitis…

Introduction

Acute cholangitis is defined as an acute inflammation of the bile ducts secondary to an infection.

The renowned pathological pathway of acute cholangitis begins with bile duct obstruction that causes cholestasis and consequent bacterial overgrowth. Therefore, the main causes of cholangitis are those pathological processes that obstruct the bile flow (e.g. cholelithiasis, bile duct or pancreatic cancer, benign biliary stricture, iatrogenic, etc…).

Acute cholangitis, like acute pancreatitis, should never be underestimated. The incidence of severe cases may be up to 12%, and its mortality ranges between 2.5% and 10%.

Diagnosis & Severity Grading

During Med School your professors probably taught you that diagnosis of acute cholangitis is defined by the so-called Charcot’s triad, enclosing fever, jaundice, and upper right quadrant abdominal pain. However, although this triad carries a high specificity, it has a low sensitivity (about 26%), and it cannot adequately classify acute cholangitis according to its severity. Therefore, diagnostic criteria must be sought somewhere else.

According to the Tokyo Guidelines 2018, acute cholangitis can be suspected or confirmed using the following criteria:

  1. Systemic inflammation
    1. Fever and/or shaking chills
    2. Laboratory data (evidence of inflammatory response)
  2. Cholestasis
    1. Jaundice
    2. Laboratory data (abnormal liver function tests such as alkaline phosphatase, GGT, transaminase
  3. Imaging
    1. Biliary dilatation
    2. Evidence of the etiology on imaging (e.g. stricture, stone, stent, cancer)

The suspicion of acute cholangitis can be placed if there is at least one item in both A and either B or C. On the other hand, the diagnosis can be confirmed if there is at least one item in each group.

The principles behind the imaging of choice to make the diagnosis are the same as in acute cholecystitis. Abdominal ultrasound should be the first-line imaging method, followed by contrast-enhanced abdominal CT scan or magnetic resonance cholangiopancreatography (MRCP)/MRI, according to the availability and the waiting time in the emergency setting. However, if possible,  MRCP/MRI should be performed before whenever there is uncertainty about the cause behind acute cholangitis.

The Tokyo Guidelines 2018, as for acute cholecystitis, define the severity assessment criteria for acute cholangitis as well:

Grade I (Mild) Acute Cholangitis
It does not meet any of the criteria of Grade II and Grade III acute cholangitis.
Grade II (Moderate) Acute Cholangitis
It has at least two of the following criteria:
– Abnormal WBC count (>12’000/mm3 or <4’000/mm3);
– High fever (Temp ≥39°C);
– Age (≥ 75 years old);
– Hyperbilirubinemia (Total Bilirubin ≥ 5 mg/dL);
– Hypoalbuminemia (<0.7 x Upper limit of normal value).
Grade III (Severe) Acute Cholangitis
It is associated with dysfunction of any one of the following organs/systems:
– Cardiovascular: hypotension requiring treatment with dopamine (≥5 μg/kg/min), or any dose of norepinephrine;
– Neurological: decreased level of consciousness;
– Respiratory: PaO2/FiO2 ratio <300;
– Renal: oliguria, creatinine >2 mg/dL;
– Hepatic: PT-INR >1.5;
– Hematological: platelet count <100,000/mm3.
Management

As already said above, acute cholangitis is no other than a bile infection, so the initial management strategy must include general supportive care and antimicrobial therapy. Afterward, further treatments should be titrated according to the severity grading and the underlying etiology.

Miura F, et al.

Blood and bile cultures should be always taken in patients affected by acute cholangitis, especially in those with Grade II or III disease. This is important because their result may help in targeting antimicrobial therapy.

Antibiotics should be administered for 4-7 days. However, in the case of positive cultures for Gram-positive bacteria (Enterococcus spp. or Streptococcus spp.), antimicrobial therapy should be prolonged for 2 weeks because these pathogens may cause infective endocarditis (its incidence among patients with acute cholangitis is 0.3%).

Something is missing, isn’t it? Something like the specific drug to give?!… Well, acute cholangitis and acute cholecystitis are both expressions of bile infection, so the antibiotics recommended are the same. You can find the recommended antimicrobial regimens in our previous post.

Biliary drainage is the mainstream of treatments, and it should be performed:

  • In Grade I – when patients fail to improve to conservative therapy after 24 h;
  • In Grade II – urgent biliary drainage;
  • In Grade III – emergency biliary drainage.

Biliary drainage can be performed endoscopically, with a percutaneous transhepatic approach, or surgically. The recommended first choice approach is the transpapillary biliary drainage (i.e. ERCP) positioning either a naso-biliary drainage or a biliary stent (the decision whether to use a plastic o a metallic stent should be made upon the etiology). Endoscopic sphincterotomy should not be performed routinely; though, it is required in case of choledocholithiasis to achieve stone removal.

After (or during) biliary drainage, the etiology should be addressed, if still needed. In Grade II and III acute cholangitis the underlying cause should be treated at the same time as biliary drainage.

That’s all folks!!!

Nothing too complex isn’t it?!… However, you should always remember that acute cholangitis, as well as acute pancreatitis, is not a thing to be taken lightly… Patients’ conditions behave the same as Hogwarts staircases in Harry Potter… They like to change… And if they do, they do it quickly and unexpectedly… We have seen young and healthy patients admitted with Grade I acute cholangitis precipitating to multiorgan failure in a handful of minutes… You should always keep your eyes wide open, and reevaluate these patients frequently…

Until next time: be good, be brave, be acute care surgeons…

References
  1. Kiriyama S, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:17-33.
  2. Miura F, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci 2018;25:31-40.
  3. Mayumi T, et al. Tokyo Guideines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:96-100.
  4. Gomi H, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:3-16.
How to Cite This Post

Bellio G, Marrano E. The Strange Story of Salmons Swimming Upstream. Surgical Pizza. Published on November 13, 2021. Accessed on November 28, 2022. Available at [https://surgicalpizza.org/emergency-surgery/the-strange-story-of-salmons-swimming-upstream/].

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