Question 9 from the second paper of 2016, and the identical Question 21 from the second paper of 2018, presented the candidates with a scenario of an elderly woman with jaundice, confusion, hypotension, fever and abdominal pain. This describes Reynolds' Pentad, the constellation of clinical signs which is actually absent in 97% of cholangitis patients. Fortunately, the modern definitions (Tokyo Guidelines, 2013) only require signs of infection and characteristic abdominal pain, with confirmation by imaging. Cholangitis is managed by draining the infected bile by ERCP, percutaneously, or via some sort of horrible surgical T-tube.
The notes below represent a brief summary of the information required to pass an "outline your management" question for the CICM Part II. It is not enough to "critically evaluate" anything, but it is unlikely that the college will ever expect generalist intensivists to have an in-depth knowledge of this hepatobiliary pathology. One might come to the conclusion that competent management of sepsis should give you half your marks, and some understanding of specific management (ERCP, cholecystostomy) would contribute the rest.
As far as published evidence and guidelines go, the following were useful resources in the creation of this summary:
The majority of this summary is guided by the 2013 Tokyo (TG13) guidelines, themselves an update of the original 2007 consensus from a conference in Tokyo.
Classically, cholangitis presents with a constellation of characteristic features.
Charcot's triad:
Reynolds pentad:
Charcot described the original triad in 1877. Benedict Reynolds (who got a pentad) and Everett Dargan (who got nothing) published their article in 1959, describing the addition to confusion and shock to the grouping of symptoms which mandate immediate surgery when present together with the original triad. These days these pentads and triads seem somewhat useless. In 2007 Rosing et al found that in their case series, only 43% of patients had Charcot's triad and only 3% had Reynold's pentad (all 117 patients had acute cholangitis by TG07 criteria, almost all required ERCP and the mortality was 25%). The new TG13 guidelines are a "duad", as they only need systemic inflammation and cholestasis:
Tokyo 2013 clinical guidelines for acute cholangitis
A. Systemic inflammation
B. Cholestasis
C. Imaging
Suspected diagnosis: One item in A and one item in either B or C
Definite diagnosis: One item in all three: A, B and C
Additionally, one may list supportive features which are not a part of the diagnostic criteria:
The purpose of imaging is to achieve a TG13-guided diagnosis, which requires two main things:
TG13 recommend specific imaging:
Gome et al (2013) offer the following list of organisms as a part of a lage scale recommendation bundle for antibiotics in cholangitis:. The bugs are listed along with the frequency with which they are isolated from bile cultures (not blood). The numbers don't add up to 100% because most commonly the bile is a sort of polymicrobial zoo. The blood cultures are often pointless. Sun et al (2016) report that bile cultures are positive in 59-93% of cases, whereas the blood cultures only yield something in 21-71%.
Gram-negatives | Gram-positives | ||
E.coli | 44% | Enterococcus sp. | 34% |
Klebsiella sp. | 20% | Streptococcus sp. | 10% |
Enterobacter sp. | 9% | Unspecified anaerobes | 20% |
Pseudomonas sp. | 20% | ||
Biliary clearance issues need to be considered. Antibiotics such as meropenem and ceftriaxone achieve high biliary concentrations. However, according to van den Hazel et al (1994), this is pure fantasy. Apparently, "there is considerable laboratory and clinical evidence that as obstruction occurs, secretion of antimicrobial agents into bile stops".
Kiriyama, Seiki, et al. "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)." Journal of hepato-biliary-pancreatic sciences 20.1 (2013): 24-34.
J. M. Charcot: Leçons sur les maladies du foie, des voies biliaires et des reins faites à la Faculté de Médecine de Paris. Recueillies et publliées par Bourneville et Sevestre. Paris: Bureaux du Progrés Médical & Adrien Delahaye, 1877. 480 pages. English translation, New York, 1878.
Reynolds, Benedict M., and Everett L. Dargan. "Acute obstructive cholangitis: a distinct clinical syndrome." Annals of surgery 150.2 (1959): 299.
Rosing, David K., et al. "Cholangitis: analysis of admission prognostic indicators and outcomes." The American Surgeon 73.10 (2007): 949-954.
Kiriyama, Seiki, et al. "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)." Journal of hepato-biliary-pancreatic sciences 20.1 (2013): 24-34.
Okamoto, Kohji, et al. "TG13 management bundles for acute cholangitis and cholecystitis." Journal of hepato-biliary-pancreatic sciences 20.1 (2013): 55-59.
Gomi, Harumi, et al. "TG13 antimicrobial therapy for acute cholangitis and cholecystitis." Journal of hepato-biliary-pancreatic sciences 20.1 (2013): 60-70.
van den Hazel, Sven J., et al. "Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis." Clinical infectious diseases 19.2 (1994): 279-286.
Sun, Zhipeng, et al. "Controversy and progress for treatment of acute cholangitis after Tokyo Guidelines (TG13)." Bioscience trends 10.1 (2016): 22-26.