Ascending Cholangitis

[VFlutter]

Lately I have had a run of patients with Ascending, or Acute, Cholangitis. They have been some of the sickest acutely ill patients I have seen. Has anyone seen this, or think that they have seen this, in the field?

Since I am lazy and do not feel like typing it out here is the wikipedia link for more info. http://en.wikipedia.org/wiki/Ascending_cholangitis

The most recent case I have seen was a result of a large cancerous tumor occluding the bile duct.

 

[chaz90]

I'm ashamed to admit I had actually never heard of this before. Cholecystitis yes, but I had never read anything about bile duct involvement, though it of course makes sense.

What in particular was notable with your patients presentation? I'm assuming markedly aggressive and resilient sepsis being the primary culprit and leading to a variety of additional problems...Liver failure too?

 

[VFlutter]

What in particular was notable with your patients presentation? I'm assuming markedly aggressive and resilient sepsis being the primary culprit and leading to a variety of additional problems...Liver failure too?

The "Classic" presentation is Charcot's traid (Jaundice, fever, and RUQ pain) and Reynolds' pentad which adds AMS and shock. Only one of the patients held true to the classic presentation, most had a mixture of symptoms but most obviously jaundice and sepsis. The one was very jaundice, fever w/ rigors, severe sepsis w/ multiorgan failure, A Fib RVR, and respiratory failure.

I think fulminate liver failure is less common but most have a transient elevation in transaminases. Kind of like with ischemic hepatitis or congestive hepatopathy. The unrelenting sepsis will eventually lead to multiorgan dysfunction.

 

[mycrofft]

Had one (of course, on a Saturday night) in custody. Presented very excitedly and demanding transport out. No fever, but ℅ were congruent. Sad to say he had to barf up what looked like fluorescent motor oil (bile to the max) before I whizzed him out and he spent a week in bed before coming back. One of those deals where I called for transport to get it rolling THEN called the doc for permission.

 

[medicsb]

Lately I have had a run of patients with Ascending, or Acute, Cholangitis. They have been some of the sickest acutely ill patients I have seen. Has anyone seen this, or think that they have seen this, in the field?

Since I am lazy and do not feel like typing it out here is the wikipedia link for more info. http://en.wikipedia.org/wiki/Ascending_cholangitis

The most recent case I have seen was a result of a large cancerous tumor occluding the bile duct.

Thinking back, I don't think I saw any cases. But, with a more simplified knowledge of disease, most paramedics wouldn't even know it exists as I did not.

Even in medical school during 3 months on surgery, I don't recall seeing a case (pre or post op). Didn't see any patients during 3 months of inpatient medicine, but we didn't see ICU patients. Overall, I do recall hearing of a doctor making a diagnosis, but I don't recall if it was on an EM rotation or when I was on surgery. Anyhow, you can be sure I was pimped multiple times on the aforementioned triad and pentad.

 

[KellyBracket]

Had one during residency. None since (that I know of...)

I bet if I were to look over the literature, I would bet that the incidence has been decreasing, for any number of reasons.

 

[Brandon O]

The "Classic" presentation is Charcot's traid (Jaundice, fever, and RUQ pain)

World's dumbest triad among a lot of dumb triads. Charcot was greedy.

 

[fma08]

World's dumbest triad among a lot of dumb triads. Charcot was greedy.

Right up there with the renal cell carinoma triad. Hematuria, abd pain, palpable mass that you'll find in less than 10% of cases.

"Classic" presentation.

 

[Brandon O]

Right up there with the renal cell carinoma triad. Hematuria, abd pain, palpable mass that you'll find in less than 10% of cases.

"Classic" presentation.

I'm okay with rare, pathognomonic syndromes. But do we really need to name things like...

Broto's Broken Leg Triad: Lower extremity angulation, local pain, and history of blunt trauma.

 

[fma08]

I'm okay with rare, pathognomonic syndromes. But do we really need to name things like...

Broto's Broken Leg Triad: Lower extremity angulation, local pain, and history of blunt trauma.

Obviously. It's named after someone, ergo, important.

 

[mycrofft]

World's dumbest triad among a lot of dumb triads. Charcot was greedy.

HAhaha! He was busy!