Endoscopic Retrograde Cholangiopancreatography or ERCP may be performed in patients for whom there is a high enough clinical suspicion for ascending cholangitis. Some sources recommend proceeding directly to ERCP if patients have all three components of Charcot's Triad PLUS elevated LFT's. ERCP is both diagnostic and therapeutic, as it allows the physician to both visualize pathology and obstruction in the duct and physically remove the offending obstruction.
In patients who do not have high enough clinical suspicion for immediate ERCP, a CT Abdomen/Pelvis may be performed to assess for the presence of common bile duct dilation or stones.
In patients suspected of having ascending cholangitis but for whom clinical suspicion is not high enough to warrant immediate ERCP, an abdominal ultrasound is commonly used to look for a dilated common bile duct or presence of stones. If this is inconclusive and a patient cannot undergo MRCP, an endoscopic ultrasound (EUS) may be performed.
CT or ultrasound may show dilated biliary ducts or stones in patients with ascending cholangitis.
To make an official diagnosis of ascending cholangitis, laboratory evidence such as elevated bilirubin is necessary. Specifically, these patients typically have an elevated direct or conjugated bilirubin component.
Elevated alkaline phosphotase, which is most commonly seen related to bile duct obstruction, inflammation, or injury, may also be seen on labs and is helpful in making a definitive diagnosis of ascending cholangitis. Notably, certain bone conditions such as tumors may also cause elevated alkaline phosphotase. An elevated GGT suggests that an elevated alk phos is due to biliary pathology and not bone pathology.
An elevated GGT indicates liver pathology, though does not indicate specifically what liver pathology. In the setting of acute cholangitis it is useful because it indicates that high alkaline phosphotase is due to biliary pathology as opposed to bone pathology.
All patients diagnosed with ascending cholangitis require treatment with broad-spectrum antibiotics, typically covering for gram positives, gram negatives, and anaerobes. Some examples commonly used include ertapenem, Pipercillin-tazobactam (Zosyn), or combinations such as Metronidazole (Flagyl) plus a cephalosporin such as Ceftriaxone or Cefazolin.
Relief of any obstruction and biliary drainage are also necessary to relieve pressure and inflammation as well as to remove any purulent or infected fluid. This can be done by various methods depending on the severity and nature of the obstruction and resulting inflammation.
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