18. Acute cholangitis, Colon cancer & Atresia of the biliary tree

What is the definition of ACUTE CHOLANGITIS?

Acute cholangitis, also called ascending cholangitis, is a bacterial infection of the biliary tract. It is often secondary to biliary obstruction and stasis.

What is the etiology of ACUTE CHOLANGITIS?

It is caused by obstruction of the biliary tree, which leads to bile stasis and subsequent bacterial infection. Common bacterial causes include E-coli, Klebsiella, Enterococcus, and Pseudomonas.

What are the risk factors of ACUTE CHOLANGITIS?

Risk factors include cholecystitis, cholelithiasis, choledocholithiasis, biliary strictures, and biliary malignancy. Iatrogenic manipulation of the bile tract is also a risk factor.

What is the pathophysiology of ACUTE CHOLANGITIS?

Biliary tract obstruction leads to bile stasis, which causes bacterial infection. This infection then ascends the biliary tract and can even track into the hepatic ducts.

What is the clinical presentation of ACUTE CHOLANGITIS?

Patients commonly present with Charcot triad: right upper quadrant abdominal pain, high fever, and jaundice. In more severe cases, Reynold's pentad, which adds hypotension and mental status changes, may be present.

What are the signs of ACUTE CHOLANGITIS?

Signs include systemic inflammation such as fever, leukocytosis, and increased CRP. Signs of cholestasis include jaundice, increased GGT, and increased ALP.

What are the symptoms of ACUTE CHOLANGITIS?

Symptoms typically include abdominal pain, commonly in the right upper quadrant, high fever, and jaundice. Patients may also show features of sepsis, septic shock, and multiorgan dysfunction.

What are the diagnostic methods (labs, imaging, physical examination) of ACUTE CHOLANGITIS and their findings?

Diagnosis is based on systemic signs of inflammation (fever, leukocytosis, increased CRP) combined with signs of cholestasis (jaundice, increased GGT, ALP, bilirubin). Imaging with ultrasound typically shows dilated common bile ducts, dilated intrahepatic bile ducts, thickened bile duct walls, or choledocholithiasis. CT with contrast or MRCP may be used if ultrasound is inconclusive or in specific cases.

What is the supportive treatment of ACUTE CHOLANGITIS?

Supportive therapy includes analgesia, such as NSAIDs or opioids. Fluid and electrolyte correction are also essential components of supportive care.

What is the pharmacological treatment of ACUTE CHOLANGITIS?

Empiric antibiotic treatment is a mainstay of therapy, often covering Gram-negative bacteria and anaerobes. Ceftriaxone plus Metronidazole is an example of empiric intravenous antibiotics used.

What is the surgical treatment/management of ACUTE CHOLANGITIS?

The underlying cause of the cholangitis should be treated, which may include the surgical removal of stones or stenting for strictures. For example, cholecystectomy can be performed for stone removal.

What are the complications of ACUTE CHOLANGITIS?

Complications can include sepsis, septic shock, and multi-organ dysfunction syndrome (MODS). Other potential complications are pyogenic liver abscess, pericholecystic abscess, and biliary stricture.

What is the definition of COLON CANCER?

Colorectal cancer is an uncontrolled cell growth originating in the colon, rectum, or appendix. The most common type is adenocarcinoma, accounting for 95% of cases.--

What is the epidemiology of COLON CANCER?

Colorectal cancer is the third most commonly diagnosed cancer in both women and men in the US. The 5-year survival rate in Europe is less than 60%.--

What is the etiology of COLON CANCER?

Polyps can transform into cancer over time, especially adenomatous polyps which are considered pre-cancerous. Other etiologies include colorectal adenomas, family history, and hereditary syndromes such as Familial Adenomatous Polyposis (FAP) with 100% risk by age 40, and Hereditary Nonpolyposis Colorectal Cancer (HNPCC) where 80% progress to CRC. Conditions like inflammatory bowel disease (ulcerative colitis and Crohn's disease), endocarditis/bacteremia due to Streptococcus gallolyticus, diet, lifestyle factors, and older age are also associated with an increased risk.--

What are the clinical features of Right-sided carcinomas (cecum and ascending colon)?

Right-sided carcinomas, which account for about 10% of cases, commonly present with iron deficiency anemia, melena, and diarrhea.--

What are the clinical features of Left-sided carcinomas (transverse and descending colon)?

Left-sided carcinomas, also about 10% of cases, manifest with changes in bowel habits (size, consistency, frequency), blood-streaked stools, and colicky abdominal pain due to obstruction.--

What are the clinical features of Rectum and sigmoid?

Cancers in the rectum (50%) and sigmoid (30%) typically present with haematochezia, decreased stool caliber (pencil-shaped stool), rectal pain, tenesmus, and flatulence with involuntary stool loss.--

What are the non-specific symptoms of COLON CANCER?

Colon cancer is often asymptomatic, especially in early stages. Nonspecific symptoms can include weight loss, fever, night sweats, fatigue, and abdominal discomfort.--

What are the diagnostic methods (labs, imaging, physical examination) of COLON CANCER and their findings?

Initial diagnosis involves a biopsy, typically performed during a colonoscopy or sigmoidoscopy. Digital rectal examination is part of the initial work-up, and complete colonoscopy is considered the gold standard. Imaging methods include CT for staging, PET, and MRI to determine the extent of local and distant metastasis, with endorectal USG, CT abdomen/pelvis/chest, and CXR also used. Carcinoembryonic antigen (CEA) serum levels are used as a tumor marker for monitoring disease recurrence and response to therapy.--

What is the systemic therapy of COLON CANCER?

Systemic therapy includes chemotherapy and biologicals. Adjuvant chemotherapy is given if lymph nodes are positive (Stage III), and palliative chemotherapy is used for metastatic disease (Stage IV). Common regimens include FOLFOX, FOLFIRI, and XELOX, and biologicals like anti-VEGF or EGFR antibodies may be added for metastatic disease. Radiation therapy is not a standard modality for colon cancer treatment.--

What is the surgical treatment/management of COLON CANCER?

For localized cancer, the preferred treatment is complete resection with adequate margins, aiming for a cure, which can be done by laparotomy or laparoscopically. Colectomy (right hemicolectomy, left hemicolectomy, sigmoid colectomy, or total abdominal colectomy) is performed depending on the tumor's location, along with regional lymph node dissection for pathologic staging. If there are resectable metastases only in the liver or lungs, they may also be removed.--

What is the definition of ATRESIA OF THE BILIARY TREE?

Atresia of the biliary tree is the obliteration or discontinuation of the extrahepatic biliary system, most commonly involving the common bile duct.

What is the etiology of ATRESIA OF THE BILIARY TREE?

The exact aetiology is unknown, but it is most likely an embryonal malformation or an acquired lesion. Rotavirus and CMV have been associated with this condition.

What is the pathophysiology of ATRESIA OF THE BILIARY TREE?

Obliteration or discontinuity of the biliary system leads to obstruction of bile flow (cholestasis). This subsequently causes secondary biliary cirrhosis and portal hypertension.

What are the clinical features of ATRESIA OF THE BILIARY TREE?

Clinical features include prolonged neonatal jaundice (typically more than 2 weeks), acholic stools, dark urine, and hepatomegaly.

What are the diagnostic methods (labs, imaging, physical examination) of ATRESIA OF THE BILIARY TREE and their findings?

Laboratory analysis shows conjugated hyperbilirubinemia, increased aminotransferases, alkaline phosphatase (ALP), and GGT. Ultrasound (USG) may reveal the absence of the gallbladder, no dilation of the biliary tree, abnormal gallbladder size/shape/contractility, or an absent common bile duct. Liver biopsy indicates active inflammation with bile duct degeneration and fibrosis. Hepatobiliary scintiscanning shows failure of the tracer to be excreted into the bowel, and intraoperative cholangiography is used to establish a definitive diagnosis.

What is the treatment of ATRESIA OF THE BILIARY TREE?

The primary treatment is the Kasai procedure (hepatoportoenterostomy), which creates a connection between the liver and the small intestine to allow bile drainage. In cases where liver cirrhosis has developed, liver transplantation is performed and is the primary reason for liver transplantation in children.