“Infection due to obstruction of the biliary tree”

Risk Factors
  • Gallstones
  • Recent biliary tract procedure or previous cholangitis.
  • Medication e.g. COCP, fibrates.
  • Lipid-rich diet – increased incidence of gallstones
Aetiology
  • Any condition causing occlusion of biliary tree.
    • Biliary calculi (80%)
    • Benign biliary stricture
    • Malignancy (cholangiocarcinoma).
  • Following biliary procedures e.g. ERCP
    • Particularly following post-op stent placement or bile duct injury (iatrogenic).
  • Obstruction of the bile duct can also result from external compression e.g. Lemmel syndrome, Mirizzi syndrome or inflammation secondary to acute pancreatitis.
  • Intrinsic obstruction can be caused by blood clots or parasites.
  • Sclerosing cholangitis (inflammation and scarring of bile ducts causing narrowing).
Pathophysiology
  • Biliary tree obstruction → bile stasis + elevated intraluminal pressure → bacterial colonisation of the duct (most commonly E. coli, Klebsiella or Enterococcus
Clinical Presentation
  • Charcot’s triad- Fever, Jaundice and RUQ pain
  • Reynold’s pentad – Charcot’s triad + hypotension and mental status changes
Investigations
  • Bloods:
    • FBC (leucocytosis)
    • LFTS (raised ALP +/- GGT and raised bilirubin)
    • Blood cultures
  • Imaging:
    • USS of biliary tract → bile duct dilation (>7mm)
  • Special:
    • Gold Standard – ERCP (Diagnosis & therapeutic)
    • May require MRCP to obtain detailed image prior to intervention
Management
  • Immediate:
    • ?sepsis → IV access → fluid resuscitation, routine bloods and blood cultures, broad spec antibiotics e.g. co-amoxiclav + metronidazole
    • Endoscopic biliary decompression (remove cause of obstruction) → via ERCP (+/- spincterotomy/stenting) or percutaneous transhepatic cholangiography if patient too sick
  • Long term:
    • Cholecystectomy if gallstones were cause, management of other underlying causes
Complications
  • ERCP complications:
    • Repeated cholangitis
    • Pancreatitis
    • Bleeding
    • Perforation

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