Snap Shot A 50-year-old woman presents with fever, jaundice, and right upper quadrant pain. Labs reveal an elevated direct bilirubin and alkaline phosphatase. Introduction Results from secondary infection of obstructed biliary tree: obstruction usually from gallstones malignancy Most common orgaisms in cholangitis are: gram negative enterics E. Coli Enterobacter Pseudomonas Most common cause of liver abscesses Sclerosing cholangits is due to progressive inflammation of the billiary tree commonly in patients with choledocholithiasis or IBD Presentation Symptoms present with Charcot's Triad (85% senstive for cholangitis) RUQ pain jaundice fever/chills Reynold's pentad Charcots triad plu hypotension altered mental status may be present in acute suppurative cholangitis Evaluation US/CT show common bile duct dilation. Diagnostic gold standard is: ERCP (endoscopic retrograde panreaticoduodenoscopy) PTCA (percutaneous transhepatic cholangiogram) Labs: neutrophillic leukocytosis increased bilirubin increased alkaline phosphatase and glutamyltransferase. Obtain blood cultures Differential Pancreatic cancer, cholangiocarcinoma, carcinoma of the bile ducts, metastatic carcinoma, primary biliary cirrhosis, cholecystitis, pancreatitis, sepsis, liver abscess. Treatment Serious life threatening condition Patients often require the ICU. Aggressive IV antibiotics. Cefazolin is the treatment of choice. If inflammation does not subside then surgery is indicated decompress the common bile duct and remove the source of obstruction. Patients with toxic cholangitis require emergent bile duct decompression with endoscopic sphincterotomy or percutenous cholecystostomy. After acute episode is controled: ERCP should be performed to locate the cause of the obstruction followed by stone removal, stent placement, or sphincterotomy Prognosis, Prevention, and Comlications 90% mortality rate in untreated patients. E. Coli septicemai is common.