Which is not a part of Charcot's triad?
Cholangitis is one of the two main complications of choledochal stones, the other being gallstone pancreatitis.
a. Acute cholangitis is an ascending bacterial infection in association with partial or complete obstruction of the bile ducts.
b. Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous bile flow and by the presence of antibacterial substances in bile such as immunoglobulin.
c. Mechanical hindrance to bile flow facilitates bacterial contamination. Positive bile cultures are common in the presence of bile duct stones as well as with other causes of obstruction. .
d. Gallstones are the most common cause of obstruction in cholangitis; other causes are benign and malignant strictures, parasites, instrumentation of the ducts and indwelling stents, and partially obstructed biliary-enteric anastomosis.
b. The patient with gallstone-induced cholangitis is typically older and female.
c. The most common presentation is fever, epigastric or right upper quadrant pain, and jaundice.
d. These classic symptoms, well known as Charcot's triad, are present in about two thirds of patients.
e. The illness may progress rapidly with septicemia and disorientation, known as Reynolds pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and mental status changes).
b. Ultrasonography is helpful if the patient has not been diagnosed previously with gallstones, as it will document the presence of gallbladder stones, demonstrate dilated ducts, and possibly pinpoint the site of obstruction; however, rarely will it elucidate the cause.
c. The definitive diagnostic test is ERC. In cases in which ERC is not available, PTC is indicated.
d. Both ERC and PTC will show the level and the reason for the obstruction, allow culture of the bile, possibly allow the removal of stones if present, and drainage of the bile ducts with drainage catheters or stents.
f. The initial treatment of patients with cholangitis includes intravenous antibiotics and fluid resuscitation.
g. These patients may require intensive care unit monitoring and vasopressor support. Most patients will respond to these measures. However, the obstructed bile duct must be drained as soon as the patient has been stabilized.
h. About 15% of patients will not respond to antibiotics and fluid resuscitation, and an emergency biliary decompression may be required.
i. Biliary decompression may be accomplished endoscopically, via the percutaneous transhepatic route, or surgically.
j. The selection of procedure should be based on the level and the nature of the biliary obstruction.
k. Patients with choledocholithiasis or periampullary malignancies are best approached endoscopically, with sphincterotomy and stone removal, or by placement of an endoscopic biliary stent.