akut kolanjit

 Clinical suspicion and evaluation — Acute cholangitis should be suspected in patients with fever, abdominal pain, and jaundice. 

●In patients with fever, abdominal pain, jaundice (Charcot’s triad), and abnormal liver tests, we proceed directly to endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis and provide biliary drainage. 

●In all other patients with suspected acute cholangitis, we perform a transabdominal ultrasonography to look for common bile duct dilatation or stones. An abdominal computed tomography (CT) is performed in patients with abdominal pain and in patients with suspected acute cholangitis who have a normal abdominal ultrasound.

If the transabdominal ultrasound and CT are normal in a patients with suspected acute cholangitis, we perform a magnetic resonance cholangiopancreatography (MRCP) . For patients who cannot undergo MRCP but have conjugated hyperbilirubinemia suggestive of biliary obstruction, we proceed with ERCP. If the liver tests are normal or if the patient is pregnant or at high risk for complications from ERCP, we perform an endoscopic ultrasound to look for evidence of bile duct stones or obstruction. If the results of ERCP or EUS are negative for biliary tract disease, alternative etiologies should be considered. 

- A pregnancy test should be performed in all women of childbearing age. Blood cultures should be performed in all patients in whom cholangitis is suspected to help direct antibiotic therapy. 

Diagnosis — A diagnosis of acute cholangitis is made if a patient has evidence of systemic inflammation with one of the following:

●Fever and/or shaking chills.

●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation).

and both of the following:

●Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate aminotransferase, to >1.5 times the upper limit of normal).

●Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or stent).

Assessment of disease severity

Severe (suppurative) cholangitis — Acute cholangitis is considered severe if it is associated with the onset of dysfunction in at least any one of the following organs/systems:

●Cardiovascular dysfunction – Hypotension requiring dopamin ≥5 micrograms/kg per min, or any dose of norepinefrin

●Neurological dysfunction – Disturbance of consciousness

●Respiratory dysfunction – PaO2/FiO2 ratio <300

●Renal dysfunction – Oliguria, serum creatinine >2.0 mg/dl

●Hepatic dysfunction – Prothrombin time-international normalized ratio >1.5

●Hematological dysfunction – Platelet count <100,000/mm

Moderate acute cholangitis — Acute cholangitis is defined as moderate if it is associated with any two of the following:

●Abnormal WBC count (>12,000/mm3, <4,000/mm3)

●Fever 39°C (102.2°F)

●Age (≥75 years)

●Hyperbilirubinemia (total bilirubin ≥5 mg/dl)

●Hypoalbuminemia

Mild acute cholangitis — Mild acute cholangitis does not meet the criteria for moderate or severe cholangitis at initial diagnosis.