急性膽道炎acute cholangitis
定義
指肝內膽管及肝外膽管之急性發炎。因為膽管是血液豐富的組織，若一旦發
生阻塞、細菌感染，細菌很容易進入血流當中發生敗血症。
病因
膽道阻塞-->引起近端感染
膽管結石(85%)
寄生蟲感染(中華肝吸蟲，泰國肝吸蟲)
惡性腫瘤(膽道,胰臟)，或良性狹窄
ERCP術後
其他可能造成膽管阻塞的因素
臨床表現
Acute cholangitis is caused primarily by bacterial infection in a patient with biliary obstruction. The organisms typically ascend from the duodenum; hematogenous spread from the portal vein is a rare source of infection
Microbiology
Culture of bile, ductal stones, and blocked biliary stents are positive in over 90 percent of cases of acute cholangitis, yielding a mixed growth of gram-negative and gram-positive bacteria. The most common bacteria isolated are of colonic origin [7]. E. coli is the major gram-negative bacterium isolated (25 to 50 percent), followed by Klebsiella (15 to 20 percent) and Enterobacter species (5 to 10 percent). The most common gram-positive bacteria are Enterococcus species (10 to 20 percent). Anaerobes, such as Bacteroides and Clostridia, are usually present as part of a mixed infection, but their frequency is underestimated by standard culture techniques. Recovery of anaerobes appears to be more common after repeated infections or surgery on the biliary tree.
Charcot's triad:發燒，右上腹痛、黃疸
儘管只有50％到75％的急性膽管炎患者同時具有這三個發現[ 8 ]。急性膽管炎最常見的症狀是發燒和腹痛，大約80％的患者可見。黃疸在60％至70％的患者中可見
Reynold's pentad:+hypotension&心智狀態改變
In addition to fever, abdominal pain, and jaundice, patients with severe (suppurative) cholangitis may present with hypotension, and mental status changes (Reynolds pentad). 此時應視為緊急狀態，病人有生命危險。 Hypotension may be the only presenting symptom in elderly patients or those on glucocorticoids
Patients with acute cholangitis can also present with complications from bacteremia, including hepatic abscess, sepsis, multiple organ system dysfunction, and shock.
出現腹膜炎表徵 (peritoneal sign)約只有15%
診斷
Lab
影像
Laboratory tests in patient with cholangitis typically reveal an elevated white blood cell count with neutrophil predominance, and a cholestatic pattern of liver test abnormalities, with elevations in the serum alkaline phosphatase, gamma-glutamyl transpeptidase, and bilirubin (predominantly conjugated) concentration [9]. However, a pattern of acute hepatocyte necrosis can be seen in which the aminotransferases may be as high as 2000 IU/L [13]. This pattern reflects microabscess formation in the liver.
血清中Alk-P或γ-GT通常也會上升
若伴隨有胰臟炎時，血清amylase/lipase也會增加
80%以上的病患其總膽紅素高於2mg/dl，且伴隨白血球增加
(leukocytosis)，其餘病患白血球可能為正常。
血液培養通常為陽性，且與
膽汁培養相同。
腹部電腦斷層：對膽管擴張之診斷率更高，且對診斷一些膽道結石併發症 (如急性胰臟炎或肝膿瘍) 之敏感度不錯，但有時無法偵測出總膽管結石。
ERCP：為診斷及治療 (引流受感染的膽汁或取石) 膽管結石的標準方法。但若ERCP失敗時，則可以施行PTCD
腹部超音波：見到CBD stone機率約50%，但75%可見總膽管擴張 (未開過膽道手術者> 7 mm 或開過刀者> 11 mm) 或肝內膽管擴張。
PTCD：也可用來診斷膽管結石的方法，也能引流受感染的膽汁或取石。對於無法施行ERCP的病患 (如無法合作及生命徵象不穩者)，可考慮施行PTCD。
總結
但診斷急性膽管炎需要全身炎症的證據，其中一種是：
•發燒和/或發冷
•發炎反應的實驗室證據(abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation).
and both of the following:
•膽汁淤積的證據：Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated ALK-P, GGT, AST or ALT, to >1.5 times the upper limit of normal
•膽道擴張的影像學或evidence of the underlying etiology(eg, a stricture, stone, or stent).
發生發燒，腹痛和黃疸的患者應懷疑是急性膽管炎。
治療
●對於同時表現發燒，腹痛，黃疸（Charcot's三聯徵）和肝功能異常的患者，我們直接進行內鏡逆行胰膽管造影（ERCP）以確診並提供膽道引流。
●在所有其他疑似急性膽管炎患者中，我們進行腹部超聲檢查以尋找膽總管擴張或結石。對腹部疼痛但腹部超音波正常的患者進行腹部CT，以排除其他原因。如果懷疑患有急性膽管炎的患者經腹超聲和CT檢查正常，我們將進行MRCP。對於不能接受MRCP但伴有提示膽道阻塞的高膽紅素血症的患者，我們進行ERCP。如果肝臟檢查正常，或者患者懷孕或患有ERCP的併發症風險很高，我們將進行endoscopic ultrasound以尋找膽管結石或阻塞的證據。
疾病嚴重程度評估
處理原則
1.禁食及輸液：若嘔吐明顯，可以放置鼻胃管引流及暫時禁食，補充適當體液。
2.抗生素：輕微者可給IVD cefazolin Q8H。嚴重者可用第三代抗生素治療。
根據嚴重程度，患有急性膽管炎的患者需要靜脈補水和糾正相關的電解質紊亂，並需要鎮痛藥來控制疼痛。此外，患者需要密切監測和治療敗血症
3.所有急性膽管炎患者均需進行膽道引流。膽汁引流的時機取決於疾病的嚴重程度。對於輕度至中度膽管炎患者，應在24至48小時內進行膽道引流。輕度至中度膽管炎患者在24小時內未對保守治療做出反應，重度（化膿性）膽管炎患者需要緊急（24小時內）膽道減壓。
內引流：若病情相對穩定，則可待隔日安排本科進行本科施行ERCP或ENBD。
外引流術：若嚴重阻塞性黃疸 (黃疸指數不斷上升) 合併生命徵象不穩定 (持續高燒、心跳血壓不穩、Lactate持續升高) 者，可照會放射科緊急施行外引流(PTCD、PTGBD)。
a. 引流之前應盡快矯正出血傾向 (如PT＜1.5 (Vit K Q12H最多打到5支 / FFP小心volume overload)、Platelet (應大於八萬)
b. 若病人可以配合呼吸和憋氣，PTCD會是引流的首選。若患者意識不清或年紀大失智症無法配合憋氣，進行PTGBD的風險會比較小。c. 一般引流管會放置四到六週後，讓皮膚和膽囊或膽管之間形成廔管 (fistula)。待臨床情況改善，可安排膽道攝影；若無阻塞，可拔除引流管。或可排PBSR以排除膽結石。另外，若臨床狀態適合手術時，可進一步會診外科開刀。
4.解決潛在的病因
在膽結石患者中，建議在膽管炎消退後進行選擇性膽囊切除術，以防止膽道絞痛的進一步發作和膽結石疾病的並發症。
對於膽管良性狹窄的患者，由於膽管損傷，可能需要內鏡治療或手術修復。
在復發性化膿性膽管炎患者中，可能需要定期進行內窺鏡檢查以清除盡可能多的結石和/或對膽腸吻合術進行手術切除受影響的肝膽段。
對於具有狹窄狹窄的患者，在內鏡下膽道引流時通常採用支架置入術。選擇的具體類型將取決於患者的預期壽命和支架阻塞的可能性。
鑑別診斷
Acute pancreatitis – Patients with pancreatitis usually present with acute onset of epigastric abdominal pain. In some patients, the pain may be in the right upper quadrant. Patients with acute pancreatitis have elevation in serum lipase or amylase to three times or greater than the upper limit of normal, and focal or diffuse enlargement of the pancreas on contrast-enhanced abdominal computed tomography (CT) or magnetic resonance imaging. (See "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Diagnosis'.)
Liver abscess – Patients with a liver abscess can present with right upper quadrant pain, transaminitis, or hyperbilirubinemia. Ultrasound and CT can differentiate between a liver abscess and acute cholangitis.
Biliary leak – Biliary leaks are a complication of bile duct injury, usually as a complication of laparoscopic cholecystectomy. Patients present with fever and abdominal pain and/or bilious ascites. On abdominal imaging, patients usually have contained, loculated collections in the gallbladder fossa (image 3) or around the liver, or can have frank, diffuse biliary peritonitis. (See "Complications of laparoscopic cholecystectomy", section on 'Biliary and cystic duct leaks'.).
Acute cholecystitis – Patients with acute cholecystitis may present with fever and abdominal pain. However, patients with acute cholecystitis should not have a significantly elevated bilirubin or alkaline phosphatase unless there is a secondary process causing cholestasis. In addition, abdominal imaging in acute cholecystitis typically reveals a normal common bile duct, gallbladder wall thickening, and a sonographic Murphy's sign. (See "Acute calculous cholecystitis: Clinical features and diagnosis", section on 'Diagnostic approach'.)