7/10/2015

AcuteCholangitisWorkup:LaboratoryStudies,ImagingStudies,Ultrasonography

AcuteCholangitisWorkup
Author:TimothyMScott,DOChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Nov10,2014

LaboratoryStudies
Laboratorystudiesincludethefollowing:
CBC:Leukocytosis:Inpatientswithcholangitis,79%hadaWBCgreaterthan10,000/mL,withameanof
13.6.Septicpatientsmaybeleukopenic.
Electrolytepanelwithrenalfunctionmaybeperformed.
Calciumlevelisnecessarytocheckifpancreatitis,whichcanleadtohypocalcemia,isaconcern.
Expectliverfunctiontestresultstobeconsistentwithcholestasis,hyperbilirubinemia(88100%),and
increasedalkalinephosphataselevel(78%).
Aspartateaminotransferase(AST)andalanineaminotransferase(ALT)levelsareusuallymildlyelevated.
Prothrombintimeandactivatedpartialthromboplastintime:Donotexpecteithertobeelevatedunless
sepsisisassociatedwithdisseminatedintravascularcoagulationorunderlyingcirrhosisexists.Acoagulation
profilemayberequiredifthepatientneedsoperativeintervention.
Creactiveproteinlevelanderythrocytesedimentationratearetypicallyelevated. [3]
Bloodcultures(2sets):Between20%and30%ofbloodculturesarepositive.Manyexhibitpolymicrobial
infections.
Urinalysisresultisusuallynormal.
Bloodtype,screen,andcrossmatch:Withurgentoperatingroomdispatch,patientsneedtohaveblood
available.
Lipase:InvolvementofthelowerCBDmaycausepancreatitisandanelevatedlipaselevel.Onethirdof
patientshaveamildlyelevatedlipaselevel.
Pancreaticenzymeelevationssuggestthatbileductstonescausedthecholangitis,withorwithoutgallstone
pancreatitis. [7]
Biliarycultures(notperformedintheED):Sendbiliaryculturesifthepatienthasbiliarydrainageby
interventionalradiologyorendoscopy.

ImagingStudies
Imagingstudiesareimportanttoconfirmthepresenceandcauseofbiliaryobstructionandtoruleoutother
conditions.UltrasonographyandCTscanningarethemostcommonlyusedfirstlineimagingmodalities.

Ultrasonography
Ultrasonographyisexcellentforgallstonesandcholecystitis.Itishighlysensitiveandspecificforexaminingthe
gallbladderandassessingbileductdilatation(seethefollowingimage).However,itoftenmissesstonesinthedistal
bileduct. [8]

Sonogramofdilatedintrahepaticducts.

Considerthefollowing:
Transabdominalultrasonographyistheinitialimagingstudyofchoice.
Ultrasonographycandifferentiateintrahepaticobstructionfromextrahepaticobstructionandimagedilated
ducts.
Inonestudyofcholangitis,only13%ofCBDstoneswereobservedonultrasonography,butdilatedCBDwas
foundin64%.
AdvantagestosonographyincludetheabilitytobeperformedrapidlyatthebedsidebytheEDphysician,
capacitytoimageotherstructures(eg,aorta,pancreas,liver),identificationofcomplications(eg,perforation,
empyema,abscess),andlackofradiation.
Disadvantagestosonographyincludeoperatorandpatientdependence,cannotimagethecysticduct,and
decreasedsensitivityfordistalCBDstones.
Anormalsonogramdoesnotruleoutacutecholangitis.

EndoscopicRetrogradeCholangiopancreatography
Endoscopicretrogradecholangiopancreatography(ERCP)isbothdiagnosticandtherapeuticandisconsideredthe
criterionstandardforimagingthebiliarysystem.
ERCPshouldbereservedforpatientswhomayrequiretherapeuticintervention.Patientswithahighclinical
suspicionforcholangitisshouldproceeddirectlytoERCP.
ERCPhasahighsuccessrate(98%)andisconsideredsaferthansurgicalandpercutaneousintervention.
DiagnosticuseofERCPcarriesacomplicationrateofapproximately1.38%andamortalityrateof0.21%.The

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majorcomplicationrateoftherapeuticERCPis5.4%,andithasamortalityrateof0.49%.Complicationsinclude
pancreatitis,bleeding,andperforation. [9]

CTScanning
CTisadjunctivetoandmayreplaceultrasonography.SpiralorhelicalCTimprovesimagingofthebiliarytree.CT
cholangiographyusesacontrastagentthatistakenupbythehepatocytesandsecretedintothebiliarysystem.This
enhancestheabilitytovisualizeradiolucentstonesandincreasesdetectionofotherbiliarypathology.
Dilatedintrahepatic(seetheimagebelow)andextrahepaticductsandinflammationofthebiliarytreeareimaged.
GallstonesarepoorlyvisualizedwithtraditionalCTscan.

CTscanofdilatedintrahepaticbileducts.ImagecourtesyofDavidSchwartz,MD,NewYorkUniversityHospital.

AdvantagesofCTincludethefollowing:
Otherpathologiesthatarecausesorcomplicationsofcholangitis(eg,ampullarytumors,pericholecysticfluid,
liverabscesses)canbeimaged.
Pathologythatmustbedistinguishedfromcholangitisalsocanbeobserved(eg,rightsideddiverticulitis,
papillarynecrosis,someevidenceofpyelonephritis,mesentericischemia,rupturedappendix).
DetectionofbiliarypathologywithCTcholangiographyapproachesthatofERCP.
DisadvantagesofCTincludepoorimagingofgallstones,allergicreactiontocontrast,exposuretoionizingradiation,
anddiminishedabilitytovisualizethebiliarytreewithelevatedserumbilirubinlevel.

MagneticResonanceCholangiopancreatography
Magneticresonancecholangiopancreatography(MRCP)isanoninvasiveimagingmodalitythatisincreasinglybeing
usedinthediagnosisofbiliarystonesandotherbiliarypathology.
MRCPisaccuratefordetectingcholedocholithiasis,neoplasms,strictures,anddilationswithinthebiliarysystem.
LimitationsofMRCPincludetheinabilityforinvasivediagnostictestssuchasbilesampling,cytologictesting,stone
removal,orstenting.Ithaslimitedsensitivityforsmallstones(<6mmindiameter).
AbsolutecontraindicationsarethesameasforatraditionalMRI,whichincludethepresenceofacardiac
pacemaker,cerebralaneurysmclips,ocularorcochlearimplants,andocularforeignbodies.Relative
contraindicationsincludethepresenceofcardiacprostheticvalves,neurostimulators,metalprostheses,andpenile
implants.
TheriskofMRCPduringpregnancyisnotknown.

Radiography
Ingeneral,abdominalfilmsaidlittleinthediagnosisofacutecholangitis.Findingsmayincludethefollowing:
Anileusmaybeobserved.
Between10%and30%ofgallstoneshavearingofcalciumand,asaresult,areradiopaque.
Filmsmayshowairinthebiliarytreeafterendoscopicmanipulationorifthepatienthasemphysematous
cholecystitis,cholangitis,oracholecysticentericfistula.
Airinthegallbladderwallindicatesemphysematouscholecystitis.

NuclearImaging
Biliaryscintigraphy(hepatic2,6dimethyliminodiaceticacid[HIDA]anddiisopropyliminodiaceticacid[DISIDA])
scansarefunctionalstudiesofthegallbladder.
ObstructionoftheCBDcausesnonvisualizationofthesmallintestine.AHIDAscanwithcompletebiliary
obstructiondoesnotvisualizethebiliarytree.
Advantagesincludetheirabilitytoassessfunctionandpositiveresultsmayappearbeforetheductsareenlarged
sonographically.
Onedisadvantageisthathighbilirubinlevels(>4.4)maydecreasethesensitivityofthestudy.Recenteatingorno
foodin24hoursalsomayaffectthestudy.Inaddition,anatomicimagingforotherstructuresislacking.Thestudy
takesseveralhours,soitisnotrecommendedincriticallyillorunstablepatients.

Procedures
EDphysiciansgenerallydonotperformproceduresforcholangitis(eg,ERCPandtranshepaticdecompression).
Ifanobstructionisobserved,ERCPprovidesdirectvisualizationandpotentialtreatment.Itisbestperformedafter
72hoursofantibioticsorafterresolutionoffever.
Inunstablepatients,areasonableoptionfordecompressionofthebiliarytractispercutaneoustranshepatic
cholangiogramandbiliarydrain.Thebiliaryductsareobserved,evenwhennoductaldilatationispresent.

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ContributorInformationandDisclosures
Author
TimothyMScott,DOChiefResident,DepartmentofEmergencyMedicine,DetroitMedicalCenter,Wayne
StateUniversitySchoolofMedicine
TimothyMScott,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,AmericanOsteopathicAssociation,EmergencyMedicine
Residents&#039Association
Disclosure:Nothingtodisclose.
Coauthor(s)
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
JeffreyAManko,MDAssistantProfessorofEmergencyMedicine,Director,EmergencyMedicineResidency
Program,ConsultingStaff,EmergencyMedicineServices,NewYorkUniversity/BellevueMedicalCenter
JeffreyAManko,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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