Gastro 54 Biliary system Gall bladder Cholecystitis Cholangitis

Charcoat’s triad (Intermittent pain, intermittent jaundice, intermittent fever) + mental status changes + shock (hypotension).

Charcot’s triad shows very high specificity. The presence of any one sign of Charcot’s triad strongly suggests the presence of acute cholangitis. However, due to the low sensitivity, it is not applicable in using as diagnosis criteria

• A. Systemic inflammation
• A-1. Fever [>38 C) and/or shaking chills
• A-2. Laboratory data: evidence of inflammatory response (WBC <4,000, or >10,000 or CRP (mg/dl) ≥1)

• B. Cholestasis
• B-1. Jaundice (≥2mg/dl)
• B-2. Laboratory data: abnormal liver function tests (>1.5 times STD)

• C. Imaging
• C-1. Biliary dilatation
• C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)

• Suspected diagnosis: One item in A + one item in either B or C
• Definite diagnosis: One item in A, one item in B and one item in C

• Grade III (Severe) acute cholangitis - It is defined as the onset of dysfunction in at least one of any of the following organs/systems:
• 1. Cardiovascular dysfunction Hypotension requiring dopamine C5 lg/kg per min, or any dose of norepinephrine
• 2. Neurological dysfunction Disturbance of consciousness
• 3. Respiratory dysfunction PaO2/FiO2 ratio < 300
• 4. Renal dysfunction Oliguria, serum creatinine > 2.0 mg/dl
• 5. Hepatic dysfunction PT-INR > 1.5
• 6. Hematological dysfunction Platelet count < 100,000/mm3

• Grade II (moderate) acute cholangitis - any two of the following conditions:
• 1. Abnormal WBC count (>12,000/mm3,<4,000/mm3)
• 2. High fever (>39 C)
• 3. Age (>75 years old)
• 4. Hyperbilirubinemia (total bilirubin >5 mg/dL)
• 5. Hypoalbuminemia (<STD X 0.7)

Grade I (mild) acute cholangitis -  does not meet the criteria of ‘‘Grade III (severe)’’ or ‘‘Grade II (moderate)’’ acute cholangitis at initial diagnosis

[Reference article - TG13 guidelines for diagnosis and severity grading of acute cholangitis]

• Grade I (mild) acute cholangitis - 
• Initial medical treatment including antimicrobial therapy may be sufficient.
• Biliary drainage is not required for most cases.
• However, for non-responders to initial medical treatment, biliary drainage should be considered after pre-intervention work-up.

• Grade II (moderate) acute cholangitis - Early endoscopic or percutaneous drainage, or even emergency operative drainage with a T-tube, should be performed in patients with Grade II acute cholangitis.
• A definitive procedure should be performed to remove a cause of acute cholangitis after the patient’s general condition has improved and following pre-intervention work-up.

• Grade III (severe) acute cholangitis 
• These patients require appropriate organ support such as ventilatory/circulatory management (non-invasive/invasive positive pressure ventilation and use of vasopressor, etc.).
• Urgent biliary drainage should be anticipated. When patients are stabilized with initial medical treatment and organ support, urgent (as soon as possible) endoscopic or percutaneous transhepatic biliary drainage or, according to the circumstances, an emergency operation with decompression of the bile duct with a T-tube should be performed.
• Definitive treatment for the cause of acute cholangitis including endoscopic, percutaneous, or operative intervention should be considered once the acute illness has resolved.

• Grade I (mild) acute cholecystitis
• Early laparoscopic cholecystectomy is the first-line treatment.
• In patients with surgical risk, observation (follow-up without cholecystectomy) after improvement with initial medical treatment could be indicated.

• Grade II (moderate) acute cholecystitis
• Elective cholecystectomy after the improvement of the acute inflammatory process is the first-line treatment.
• Early laparoscopic cholecystectomy could be indicated if advanced laparoscopic techniques are available.
• If a patient does not respond to initial medical treatment, urgent or early gallbladder drainage is required.
• Grade II (moderate) acute cholecystitis with serious local complications is an indication for urgent cholecystectomy and drainage.

• Grade III (severe) acute cholecystitis
• Appropriate organ support such as ventilatory/circulatory management (noninvasive/invasive positive pressure ventilation and use of vasopressors, etc.) in addition to initial medical treatment is necessary.
• Urgent or early gallbladder drainage should be performed.
• Elective cholecystectomy may be performed after the improvement of acute illness has been achieved by gallbladder drainage. 

[Reference article - TG13 flowchart for the management of acute cholangitis and cholecystitis]

Inflammatory disease of gall bladder without the evidence of gall stones or cystic duct obstruction. 

• Etiololgy -
• 1) Depressed motility and starvation - surgery, burns, >3 months of TPN, narcotic analgesics 
• 2) Decreased blood flow through cystic artery - atherosclerosis, congestive heart failure, diabetes, shock
• 3) Infection (sepsis/immunocompromised) - AIDS
• 4) Obstruction of cystic duct by extrinsic inflammation - lymphadenopathy, metastasis 

• Investigations - 
• - USG
• - HIDA scan 

• Treatment - 
• - Cholecystectomy 
• - Cholecystostomy for non surgical candidate