ZSFG GI report – choledocholithiasis cholangitis, and cholesterol stones

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
Top pearls
  • 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
Diagnosis
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
cholangitis-diagnostic-criteria
Treatment:
  • 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

cholangitis grading.JPG

  • Use your pretest probability of cholangitis and the Grade (or severity) of cholangitis to determine timing of ERCP
cholangitis management algorithm.JPG
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
Sources:
Evernote (without the images, evernote isn’t into images this morning) https://www.evernote.com/shard/s192/sh/d22f552e-36b4-4bbf-a91b-7afcc4251a6e/59f30de2a4572ef348ff8f7dff8f2afc
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