Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- right upper quadrant (RUQ)/upper abdominal pain
- RUQ/upper abdominal tenderness
- jaundice
- fever
Other diagnostic factors
- pale stools
- pruritus
- hypotension
- mental status changes
Risk factors
- age >50 years
- cholelithiasis
- benign stricture
- malignant stricture
- post-procedure injury of bile ducts
- history of primary sclerosing cholangitis
- history of secondary sclerosing cholangitis
- HIV infection
Diagnostic investigations
1st investigations to order
- FBC
- serum urea
- serum creatinine
- ABG analysis
- serum LFTs
- CRP
- serum potassium
- serum magnesium
- blood cultures
- coagulation panel
- transabdominal ultrasound
- endoscopic retrograde cholangiopancreatography (ERCP)
Investigations to consider
- abdominal CT scan with intravenous contrast
- magnetic resonance cholangiopancreatography (MRCP)
- percutaneous trans-hepatic cholangiography (PTC)
- endoscopic ultrasonography (EUS)
Treatment algorithm
acutely ill
with choledocholithiasis, PSC, or HIV cholangiopathy
Contributors
Expert advisers
Douglas G. Adler, MD, FACG, AGAF, FASGE
Professor of Medicine
Division of Gastroenterology
Department of Internal Medicine
Huntsman Cancer Institute
University of Utah
Salt Lake City
UT
Disclosures
DGA has consulted for Boston Scientific, Merit Medical, and Olympus, who make endoscopic retrograde cholangio-pancreatography (ERCP) products, and has also consulted for AbbVie Pharmaceuticals. He is an author of references cited in this topic.
Peer reviewers
Christian Macutkiewicz, MD, FHEA, FRCS
Consultant General & Hepato-Pancreato-Biliary (HPB) Surgeon
Manchester Royal Infirmary
Manchester
UK
Disclosures
CM declares that he has no competing interests.
David J. Hackam, MD, PhD
Associate Professor of Pediatric Surgery
University of Pittsburgh School of Medicine
Pittsburgh
PA
Disclosures
DJH declares that he has no competing interests.
Todd Baron, MD
Professor of Medicine
Division of Gastroenterology & Hepatology
Mayo Clinic Rochester
Rochester
MN
Disclosures
TB declares that he has no competing interests.
Dennis Freshwater, MB, BS, MD, FRCP
Consultant Hepatologist
The Liver and Hepatobiliary Unit
Queen Elizabeth Medical Care Unit
University Hospitals Birmingham NHS Foundation Trust
Birmingham
UK
Disclosures
DF declares that he has no competing interests.
Bertus Eksteen, MRCP, PhD, MRC
Clinical Scientist
University of Birmingham
Honorary Consultant
Liver Transplant Unit
University Hospitals Birmingham NHS Foundation Trust
Birmingham
UK
Disclosures
BE declares that he has no competing interests.
Editors
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Anna Ellis
Head of Editorial, BMJ Best Practice
Disclosures
AE declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Differentials
- Acute cholecystitis
- Peptic ulcer disease
- Acute pancreatitis
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