Thank you to Bridget Keenan for presenting a fascinating case of a patient s/p remote cholecystectomy with presented with cholangitis 2/2 an impacted CBD stone
- use the Tokyo 13 criteria to diagnose cholangitis and assign it a grade and the Tokyo 13 algorithm to manage cholangitis
- always ask your patients about how they got their abdominal (and other surgical) scars!
Diagnosis and management of Cholangitis
First, make the diagnosis of cholangitis (it’s not easy!)
- Charcot’s triad (fever, jaundice, and RUQ pain) is 96% specific for cholangitis but only 26% sensitive
- the Tokyo 13 criteria are 92% sensitive and 78% specific
- It is critical to distinguish between cholangitis and cholecystitis, but easy in this patient because he did not have a gallbladder =)
The Tokyo 13 criteria are below
- As with any other sepsis, the pillars of management are resuscitation, antibiotics, and source control. We all fear pus under pressure in the biliary tree
- Use your pretest probability of cholangitis and the Grade (or severity) of cholangitis to determine timing of ERCP
bonus pearl 1 – colon cancer history
- in patients with discontinuous access to health care or who have moved around a lot I often find myself attempting to glean their complex medical history Sherlock Holmes style. Dr. Cello guided us through some high yield questions for patients with a history colon cancer
- where is their scar?
- did they have radiation, chemotherapy, or both and in what order?
- from those two you can usually glean the stage and location of surgery
bonus pearl 2 – pathophysiology of cholesterol stones
- Cholesterol stones need two things to form nucleation and stasis
- They are very slow growing
- 100% of bile duct stones are contaminated with gram negative rods
Miura F1, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Yoshida M, Mayumi T, Okamoto K, Gomi H, Kusachi S, Kiriyama S, Yokoe M, Kimura Y, Higuchi R, Yamashita Y, Windsor JA, Tsuyuguchi T, Gabata T, Itoi T, Hata J, Liau KH; Tokyo Guidelines Revision Committee.TG13 flowchart for the management of acute cholangitis and cholecystitis.J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):47-54
Takada T1, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, Mayumi T, Miura F, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Yokoe M, Kimura Y, Tsuyuguchi T, Itoi T, Gabata T, Higuchi R, Okamoto K, Hata J, Murata A, Kusachi S, Windsor JA, Supe AN, Lee S, Chen XP, Yamashita Y, Hirata K, Inui K, Sumiyama Y; Tokyo Guidelines Revision Committee.
Evernote (without the images, evernote isn’t into images this morning) https://www.evernote.com/shard/s192/sh/d22f552e-36b4-4bbf-a91b-7afcc4251a6e/59f30de2a4572ef348ff8f7dff8f2afc