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