colangitis

COLANGITIS

In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. With septic shock the diagnosis can be missed in up to 25% of patients. Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain. A history of abdominal pain or symptoms of gallbladder colic may be a clue to the diagnosis.

·                Charcot's triad consists of fever, RUQ pain, and jaundice. It is reported in up to 50-70% of patients with cholangitis. However, recent studies believe it is more likely to be present in 15-20% of patients.

·                Fever is present in approximately 90% of cases.

·                Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively.

·                Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs, combined with Charcot's triad, constitute Reynolds pentad.

·                Consequently, many patients with ascending cholangitis do not present with the classic signs and symptoms.

·                Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.

·                Other symptoms include the following:

·                                  Jaundice

·                                  Fever, chills, and rigors

·                                  Abdominal pain

·                                  Pruritus

·                                  Acholic or hypocholic stools

·                                  Malaise

·                The patient's medical history may be helpful. For example, a history of the following increases the risk of cholangitis:

·                                  Gallstones, CBD stones

·                                  Recent cholecystectomy

·                                  Endoscopic manipulation or ERCP, cholangiogram

·                                  History of cholangitis

·                                  History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidiuminfections. The management of this condition is described below, although decompression is usually not necessary.

Hepatitis A

One of the more common causes of acute hepatitis is hepatitis A virus (HAV), which was isolated by Purcell in 1973. Humans appear to be the only reservoir for this virus. Since the application of accurate serologic investigations in the 1980s, the epidemiology, clinical manifestations, and natural history of hepatitis A have become apparent.

The relative frequency of HAV as a cause of acute hepatitis has declined in Western societies, while in contrast, notification of individual cases has increased, primarily as a result of improved reporting and diagnostic techniques. The nadir of reported cases was in 1987.

Improvements in hygiene, public health policies, and sanitation have had the greatest impact on hepatitis A, and vaccination and passive immunization have successfully led to some reduction in illness in high-risk groups.

Reduced encounters with HAV at a young age have resulted in both a decline in herd immunity and a change to the epidemiology of the illness, with increases in the mean age of occurrence of illness attributed to acute HAV infection in Western societies. Although this phenomenon may lay a framework for potential epidemics in the future, public health policies and newly implemented immunization practices are likely to reduce this potential.

Most patients have no defined risk factors for hepatitis A. Risk factors for the acquisition of hepatitis A include the following:

·                Personal contacts

·                Institutionalization

·                Occupation (eg, daycare)

·                Foreign travel

·                Male homosexuality

·                Illicit parenteral drug use

HAV is a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and synthesis, and assembly occurs exclusively in liver cells. Acquisition results almost exclusively from ingestion (eg, fecal-oral transmission), although isolated cases of parenteral transmission have been reported.

HAV is an icosahedral nonenveloped virus measuring approximately 28 nm in diameter (see the image below). Its resilience is demonstrated by its resistance to denaturation by ether, acid (pH 3.0), drying, and temperatures as high as 56°C and as low as -20°C. The hepatitis A virus can remain viable for many years. Boiling water is an effective means of destroying it, and chlorine and iodine are similarly effective.