Cholecystitis vs Ascending cholangitis

[Phloston]

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I was wondering if someone could be very specific as to how to differentiate ascending cholangitis from cholecystitis.

Reynold's pentad for ascending cholangitis is fever, RUQ pain, jaundice, hypotension and mental status change.

In cholecystitis, couldn't we also have all of those symptoms?

The other thing is ALP could be raised in both if the inflammation becomes severe, leading to jaundice.

Anyone's thoughts would be great. Cheers,

 

[AndyRSC]

In real life, the diagnosis mostly rests with ultrasound +/- HIDA, MRCP, etc. People do have classic presentations, but it's not always as clear-cut as a USMLE question is going to be.

Expect to see a lot of stereotypical wordplay thrown at you if they're going to make you differentiate between something like this. On physical exam, they'll tell you you have Murphy's or Boas sign (or they will describe the finding, given that we're moving away from eponyms and buzzwords).
Bilirubin, ALP, and GGT don't have to be elevated in cholecystitis, or the elevations will be slight. They almost always will be in cholangitis, and will be higher. Thus, jaundice is also more specific to cholangitis.
If the question gives you ultrasound findings (e.g. gallbladder wall thickening with pericholecystic fluid), that will essentially give it away.
Reynold's pentad (and even Charcot's triad) are uncommon presentations, but if you have a question on something so difficult to differentiate on an exam, they'll likely give you classic/stereotypic presentations, so septic features will likely point to cholangitis. People have to be pretty far-gone with their cholecystitis before they get this, and the mechanism of cholangitis makes it more likely.

That's about all I can think of. Feel free to chip in.

 

[Dissected]

It's kind of a continuum of gallbladder pathology and you would be amazed at how much overlap there is with how these things present.

In general, if you have a patient who has ruq pain, fever, high white count, and prolonged bile stasis (ie a common duct stone), cholangitis should be suspected. Bile stasis predisposes to this condition. Symptoms of shock raise concern even more that there is an organism infecting the biliary tree. A patient with signs of gallbladder disease who is very sick is basically what you are looking for.

Remember, in real life charcots triad presents in less than 50%, and jaundice is the most variable component. On the boards..charcots triad/Reynolds pentad are reliable

 

[Phloston]

Cheers for your thoughts there, guys.

My take would therefore be that leukocytosis and fever, with jaundice and RUQ, in terms of the USMLE, would be ascending cholangitis, particularly if ALP and conjugated bilirubin were elevated. There's definitely overlap, but one should just be watchful.

I think the other big thing is that cholecystitis is generally more of a constant pain whereas ascending cholangitis is more colicky. Is that correct?

I have annotated into my FA from USMLE Rx: "For cholecystitis, ESR is increased and pain is constant; LFTs are "usually" normal. Not only is pain constant, but it is colicky with ascending cholangitis."

 

[AndyRSC]

Not only is pain constant, but it is colicky with ascending cholangitis.

Not sure I follow. USMLE Rx says that pain is constant but colicky?

That is more representative of biliary colic (even though biliary colic itself is often persistent) and maybe choledocholithiasis. Once the duct becomes infected and inflamed, the pain is unlikely to subside. Is that what it was talking about?

 

[Dissected]

I have annotated into my FA from USMLE Rx: "For cholecystitis, ESR is increased and pain is constant; LFTs are "usually" normal. Not only is pain constant, but it is colicky with ascending cholangitis."

Careful...colicky pain is pain that waxes and wanes; it is best thought of as intermittent. So you wouldn't have constant and colicky pain all in one because they mean different things. So--biliary colic is a misnomer because the pain is usually considered to be constant. Fun fact that surgery residents like to pimp med students on.

I'm really not sure how one would differentiate these entities based on the pain pattern.

 

[Phloston]

Not sure I follow. USMLE Rx says that pain is constant but colicky?

That is more representative of biliary colic (even though biliary colic itself is often persistent) and maybe choledocholithiasis. Once the duct becomes infected and inflamed, the pain is unlikely to subside. Is that what it was talking about?

It gave a vignette of the classic 4Fs (fertile, forty, female, fat), colicky pain and mentioned a fever, then asked for the Dx. The answer was ascending cholangitis based on the fact that she had a fever. ~10% got it right. Everyone jumped on cholesterol cholelithiasis. The idea was that it presented exactly like stones (since that can be an aetiology of AC), but that one needs to be aware of the fever and/or leukocytosis.

Cholecystitis, however, is constant pain because the inflammation is of the gallbladder itself and no longer just dependent on the stones (if they're the aetiology).

 

[ijn]

eMedicine's article on cholecystitis includes a statistic that only 10% of the cases demonstrate fever. I'd buy that as a valid discriminator if pressed to pick between ascending cholangitis and cholecystitis. I think the other classic test that the NBME might like to use to discriminate between the two is Murphy's sign.