ERCP plays a key role in the management of acute cholan-gitis. The most common cause of cholangitis is choledo-cholithiaisis, and it occurs in approximately 80% of cases of cholangitis. Other causes of acute cholangitis include congenital abnormalities of the biliary tree (choledochal cyst), and malignant obstruction of the biliary tree from ampullary tumors, cholangiocarcinoma, and pancreatic tumors. The management of malignant biliary obstruction and congenital abnormalities will be discussed in other sec-
tions of this text. In patients with benign strictures such as primary sclerosing cholangitis and CBD stricture due to chronic pancreatitis, cholangitis can be the presenting symptom or the result of duct manipulation during ERCP or percutaneous cholangiography. The classic presentation of acute cholangitis includes Charcot's triad (right upper quadrant pain, fever, and jaundice). Most cases of cholan-gitis are mild, but 15 to 20% of cases are severe, and require emergent intervention. In severe cases, patients may present with Reynolds pentad of right upper quadrant pain, fever, jaundice, altered mental status, and shock. Patients with suspected cholangitis usually have elevation of the bilirubin, alkaline phosphatase, and transaminases. Initial management of patients should include blood cultures, administration of broad spectrum antibiotics, intravenous fluids, and urgent right upper quadrant US to detect presence of cholelithiasis and biliary dilatation. If the patient fails to quickly respond to conservative management, then urgent ERCP is necessary. The goal of endoscopic management with ERCP is affecting drainage of infected bile. Endoscopic sphincterotomy with complete clearance of the bile duct of stones is the goal of treatment in stable patients. However, placement of a stent or nasobiliary drain is all that is required to stabilize the patient. Cholangitis can reoccur despite endoscopic sphincterotomy due to retained stones. If complete clearance of the CBD cannot be achieved, then a plastic stent should be left in the CBD, and antibiotics should be continued for 10 to 14 days. Clogged biliary stents are another common cause of cholangitis. The clinical presentation of these patients may be mild with subtle symptoms such as malaise, low grade fever, and mild jaundice. The clogged stent should be removed/exchanged urgently to avoid the development of more severe cholangitis.
The role of ERCP in acute pancreatitis involves the treatment of an impacted or ball-valving CBD stone. Gallstones are implicated in 50 to 80% of cases of acute pancreatitis. Supportive care is the mainstay of treatment for acute gallstone pancreatitis, but early recognition of gallstone pancreatitis is imperative. Abdominal imaging with US demonstrating the presence of cholelithiasis and elevated transaminases have a high predictive value for diagnosing acute gallstone pancreatitis. The timing of endoscopic sphincterotomy with stone extraction should be performed in specific clinical scenarios either before or after chole-cystectomy. ERCP should be performed before cholecys-tectomy if the patient has concomitant cholangitis, obstructive jaundice, or severe pancreatitis not responding to conservative measures. However, preoperative ERCP is of low yield and is not indicated in the majority of patients with resolving or normal liver enzymes. Patients should undergo intraoperative cholangiography with ERCP reserved to those with positive findings.
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