Hepatobiliary Infections
GENERAL PRINCIPLES
• Acute cholecystitis is associated with cholelithiasis and is caused by intestinal flora including E. coli,
Klebsiella, Enterobacter, etc. Acalculous cholecystitis occurs in 5%-10% of cases.
• Ascending cholangitis is a fulminant infectious complication of an obstructed common bile duct, often following pancreatitis or cholecystitis.
DIAGNOSIS
Clinical Presentation
Tenderness and guarding of the right upper quadrant (RUQ) on deep inspiration (Murphy sign) is a common sign of a hepatobiliary infection. Ascending cholangitis presents as the Charcot triad of fever, RUQ pain, and jaundice. Reynolds pentad adds symptoms of confusion and hypotension and warrants rapid intervention. Bacteremia and shock are common.
Diagnostic Testing
• Elevated liver enzymes in a cholestatic pattern suggests acute cholangitis.
• Diagnosis of biliary tract infections is usually made by imaging with ultrasonography. Cholescintigraphy using technetium-99m hydroxy iminodiacetic acid scanning (also referred to as HIDA scan) and CT scanning may also be useful.
• Endoscopic retrograde cholangiopancreatography serves as diagnostic and therapeutic intervention for common bile duct obstruction and allows for stone extraction and/or biliary stent insertion.
TREATMENT
• Management of acute cholecystitis includes parenteral fluids, restricted PO intake, analgesia, and surgery. Advanced age, severe disease, or complications such as gallbladder ischemia or perforation, peritonitis, or bacteremia mandate broad-spectrum antibiotics such as ampicillin/sulbactam 3 g IV q6h, piperacillin/tazobactam 3.375 g IV q6h, ertapenem 1 g IV qday, or meropenem 500 mg IV q8h. Immediate surgery is indicated for severe or complicated disease but may be delayed up to 6 weeks if there is an initial response to medical therapy. After cholecystectomy, perioperative antibiotics may be discontinued.30
• Ascending cholangitis requires aggressive supportive care, including broad-spectrum antibiotics as above. Surgical or endoscopic decompression and drainage is necessary. Development of an abscess requires surgical drainage.