Acute cholangitis tips, PKD complications pearls

 

AM Report Pearls: Acute Cholangitis Tips

  • Dx: Charcot’s triad = fever, RUQ pain & jaundice only seen in 50-75% of patients!
    • Reynold’s Pentad adds hypotension & altered mental status
  • Micro: Bile/biliary stent cultures are positive >90% of the time! Blood cultures are positive ~50% of the time!
    • coli in 25-50% of patients
    • Klebsiella in 15-20% of patients
    • Enterobacter in 5-10% of patients
    • Enterococcus in 5-10% of patients
    • Anaerobes (Bacteroides, Clostridia) are rare and usually part of a polymicrobial infection
  • Management: ~80% of patients respond with conservative therapy (Abx, fluids, etc.) while 15-20% will require urgent biliary decompression by ERCP – so call Hepatobiliary early!
    • Mortality in untreated cholangitis ranges from 20-60%
    • Empiric therapy for broad Gram-negative coverage is key – consider Ertapenem, Pip-tazo, or combination of FQ + Metronidazole
      • To Chelsea’s point this morning, Amp-Sulbactam is a good alternative too, but some institutions have high E. coli resistance to Amp-Sulbactam so check your local susceptibilities!
    • Great review article on dx & management of cholangitis attached!

 

AM Reports Pearls: Polycystic Kidney Disease Complications

  • Common Intra-renal complications:
    • Increased risk of renal failure: APKD increases risk of renal failure, requires HD in <2% of the time in pts under 40 but risk increases to 50-75% of time in pts >70 yrs
    • Increased risk of HTN: Occurs in 60-70% of pts with normal kidney function, and over 90% of patients will have HTN by the time they reach end-stage renal disease
    • Increased risk of cyst infection: 30-50% of pts have at least one cyst infection
    • Hematuria: Seen in 30-50% of PKD patients, often caused by bleeding into a cyst
    • Nephrolithiasis: Seen in 25% of PKD patients
    • Flank/abdominal pain: Very common due to pressure from enlarging cyst! NSAIDS are NOT recommended to treat this pain!
  • Common Extra-renal complications:
    • Intracranial aneurysm: 3-7% of patients have it but this risk is much higher with family history
    • Liver cysts: Seen in 85% of PKD patients
    • Heart valve disease: Valve abnormalities seen in ~25% of PKD patients
    • Abdominal wall hernias: Seen in ~45% of PKD patients
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