Talk:Ascending cholangitis

Requested move
Why is this article named Ascending cholangitis? It is not the most common use (googling ascending cholangitis gives ~50.000 results, compared to cholangitis, which gives more than 700.000). Besides, "ascending" isn't even mentioned in the article itself! I suggest a move. Mikael Häggström 09:36, 19 July 2007 (UTC)


 * Never mind. There were other causes of cholangitis than ascending cholangitis. Thus another article is now created of cholangitis. Mikael Häggström 10:15, 19 July 2007 (UTC)

Agenda for MCOTW
This article has the benefit of being in an absolutely dreadful state at present, so even small improvements will have quite an impact on its readability and usefulness for the general reader. It is a clinically interesting condition as it crosses the borders between infectious diseases, gastroenterology, surgery and radiology. Consequently, it has no specialist ownership - in the UK a patient with ascending cholangitis may be admitted under internal medicine or surgery.

I am, however, worried about the paucity of free sources. There have been no major reviews in the Lancet, N Engl J Med, BMJ, JAMA (which carries few reviews to begin with) and Ann Intern Med. The most appropriate source from my perspective is, which is non-free. I will (as we tried on pectus excavatum) try to approach the author for a limited number of reprints. If this fails, we may need to resort to popular textbooks, with the problem that these are not readily available for verification. JFW | T@lk  20:56, 12 June 2008 (UTC)


 * Why have textbooks been considered to be unreliable? Because of lack of accessibility or their reliability is considered suspect? Also, in verifiability, I felt the textbooks have been put at par with journal articles, except for that the latter have been somewhat preferred. I was asking as I'm planning to cite textbooks only in my attempt at expansion, and have used mainly textbooks for citing facts in the article polyclonal response. Regards.  —Ketan Panchal  t aL K  07:36, 14 June 2008 (UTC)


 * Well it depends on the nature of the topic. With topics such as this where there is ongoing research text books may not be as up to date as journal articles. Thats the main reason. But you can still use textbooks, especially if they are updated regularly. The other issue is journals are readily available on the internet so other users can easily check them. Hope that answers your question. Btw, JFW I have access to the article you mentioned. Are you asking the author permission to distribute a few copies of the article around to other editors? Ziphon (ALLears) 05:33, 15 June 2008 (UTC)


 * Textbooks, in my experience, are too concise and almost by definition do not cite their sources adequately. In Harrison's, you can only guess which content from an entry is to be traced to which reference.
 * Dr Kinney has kindly sent me a copy of the article. Although I asked him, he didn't directly comment on us sharing copies. JFW | T@lk  11:02, 15 June 2008 (UTC)


 * Hi! Totally agreed that textbooks don't cite their source. But what about the fact that textbooks, as they are considered reliable enough to be primarily sources? Can't they primarily be considered as sources?  —Ketan Panchal t aL K  13:30, 15 June 2008 (UTC)


 * Perhaps this is just me but I have several books (admittedly not on this subject) which do cite their sources in bibliographies? Regards, CycloneNimrod talk? contribs? 14:25, 16 June 2008 (UTC)

A few doubts and issues
Hi everyone!
 * "Ascending cholangitis or acute cholangitis is an infection of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine)."
 * Are ascending and acute cholangitis synonyms?
 * Would it be better to define the condition as infection or inflammation? Of course, the etiology is bacterial, so is ultimately an infection only.
 * Is some short introduction on functions of liver, gall bladder and bile duct required?
 * The section on "Signs and symptoms" talks only of the clinical features without distinguishing between signs and symptoms. Is this distinction required to be made in the section? Most of the general public isn't usually aware of the distinction.

Well, to begin with I've started with wikilinking of a few terms. Will try to expand it further. But, nice topic indeed for collaboration of the fortnight, despite the fact that I'd nominated Lymphatic system. Regards.  —Ketan Panchal t aL K  07:26, 14 June 2008 (UTC)


 * Ascending and acute cholangitis are indeed synonyms. Other forms of cholangitis (such as primary sclerosing cholangitis) are not ascending and they also don't tend to be acute. Inflammation due to bacteria is always synonymous to infection (unless it is a bystander effect due to molecular mimicry, which is unusual in bacteria).
 * I think the function of the liver shouldn't need discussion, but the purpose of the bile duct may need to be explained at some point as not everyone knows how bile from liver reaches the small intestine.
 * Symptoms and signs should ideally be separated, as the symptoms prompt people to seek healthcare. The signs are then elicited by a healthcare professional. The problem is here that Charcot's and Reynolds' rules of thumb include both symptoms and signs. Therefore, we should use our references to list symptoms, and then signs, and then discuss the triad and pentad.
 * KC, have you got access to Kinney's good review that I linked above? JFW | T@lk  11:02, 15 June 2008 (UTC)

Section on pathophysiology

 * Yes, by function, I'd meant only the function of bile, bile duct, gall bladder, etc., and not the entire range of liver functions.
 * Looking forward to making a few edits, now. ;)  —Ketan Panchal t aL K  13:55, 15 June 2008 (UTC)

We do not need an entire section on the structure and function of the bile duct. A few words will do in the intro, and some more detail in the pathophysiology section. JFW | T@lk  16:04, 15 June 2008 (UTC)


 * Well, I thought those points would be necessary for an uninitiated reader to understand the pathogenesis (stasis, infection "ascending" from the sphincter of Oddi, etc). Moreover, my idea is that for a few days, let the editors add the content they feel is necessary, and later in an "organization" step, the text can be reorganized (which may include deletion, too of material deemed unnecessary) into appropriate sections. Also, the title I gave to the section is partly because I didn't want to use technical terms like anatomy or physiology. Regards.  —Ketan Panchal t aL K  16:26, 15 June 2008 (UTC)


 * Please have a look at WP:MEDMOS, which is our consensus outline for medical articles. Generally, nobody has a problem with using headings like "pathophysiology" etc.
 * My problem with "editors adding content they feel is necessary" is that the article might get rather full of stuff that will later require revising and shifting. I have taking the liberty of working the content on the function of the bile duct into a new "pathophysiology" section. I will be expanding with the use of Kinney's review. JFW | T@lk  10:21, 16 June 2008 (UTC)
 * Thanks for pointing out WP:MEDMOS. Also, the changes you made to the section are absolutely agreeable. Do you feel the position of the section "Pathophysiology" (i.e., sequence of sections) is alright, or should it be moved up the order? Bye the way, I took the liberty of clubbing this thread into a subsection for easy editing and navigation through the page. Is that alright?  —Ketan Panchal t aL K  10:45, 16 June 2008 (UTC)

Section on Signs and symptoms
I have replaced the term "mnemonic" in this section with "set" as I feel the term mnemonic is usually reserved for a memory aid (say involving a play of words, or witty sentence), whereas Charcot's triad isn't that. Also, may be definition of steatorrhea requires the stool to be fatty and foul-smelling (may be stea=fat; like stearic acid), and not exactly white. So, do we need to modify that part?  —Ketan Panchal t aL K  14:17, 16 June 2008 (UTC)


 * I agree that "mnemonic" wasn't an ideal choice.
 * I'm a bit unsure about listing steatorrhoea to begin with. Kinney makes it clear that complete biliary obstruction (which would lead to steatorrhoea) is quite unusual in cholangitis. I have no objection to removing it alltogether. Otherwise, the classic description of steatorrhoea is "pale, foul-smelling and hard to flush". JFW | T@lk  15:27, 16 June 2008 (UTC)

The hard bit
Given the patchy nature of the literature on this condition, it will be very hard to populate sections on "epidemiology", "prognosis" and "history". Kinney's article doesn't mention those.

For the purposes of history, we can say a word or two about Charcot and Reynolds, whose triad and pentad respectively made quite a lot of impact on the recognition of this illness, but otherwise there's really not an awful lot to say. JFW | T@lk  16:41, 16 June 2008 (UTC)


 * What a surprise: JFW |  T@lk  16:56, 16 June 2008 (UTC)

The lead
It says that hypotension and confusion are also characteristic symptoms, but later in the article it is revealed that even the 'Charcot's triad' is now becoming a rare finding, and that the Reynold's pentad (which includes these two symptoms) is further rare to find. So, would be alright to not quote them as at least "characteristic symptoms"?

Can the portion be changed to something like this: "Characteristic symptoms include jaundice, fever and abdominal pain. Low blood pressure and confusion may develop with worsening of condition (or developing shock)."

I have not made these changes myself as I'd be afraid that, doing so shouldn't upset or offend you in any way. If you're alright with my making changes, I'll make them now on, and of course you can revert them if they are not agreeable with you.

Regards.

 —Ketan Panchal t aL K  09:41, 17 June 2008 (UTC)


 * I have improved this. JFW | T@lk  18:06, 17 June 2008 (UTC)

Now, then
I've pretty much filled the main sections with stuff from Kinney's fairly comprehensive article. The following issues remain from my perspective:
 * I still need to mention the need for cholecystectomy in patients who have been treated for ascending cholangitis due to gallstones. ✅
 * Kinney is not specific as to the incidence of tumours causing cholangitis, but says that it is rare. Numerical data would be nice although not crucial (as it depends on the population and age group anyway). ✅
 * In this regard, may be some textbook might be helpful. I'll try to find&mdash;I have Harrison's, Schwartzs' and CSDT.  —Ketan Panchal t aL K  09:23, 17 June 2008 (UTC)
 * We have no epidemiology (e.g. incidence, age and sex preponderance) and prognosis data. Looking at the Emedicine article, much of this is based on personal experience of the authors and I'm not very keen to cite Emedicine as the only source for this information.
 * Again, the above textbooks could be useful, if you agree.  —Ketan Panchal t aL K  09:23, 17 June 2008 (UTC)
 * More historical context would be useful, as the present section is cobbled together from sources mentioned in Kinney.
 * I'm not sure which aspect of the history would be pertinent. Unfortunately, this is not an syndrome-like infectious disease (like say tuberculosis or malaria) that we can discuss the causative organism, nor is it a genetic disorder that we can talk of discovery of certain gene. I'm saying this, may be because I'm short of ideas.  —Ketan Panchal t aL K  09:23, 17 June 2008 (UTC)
 * The article is not complete until the brand new British guidelines on common bile duct stones have been mentioned. I will read this new guideline tonight and try to include it. ✅
 * What surgical approaches were used in the pre-ERCP era? ✅

I would love some feedback on my expansion over the last 24 hours. JFW | T@lk  06:39, 17 June 2008 (UTC)


 * I've been going through the article. I was in doubt as to what length (or level of details) have you in mind for the article. This I'm saying as I felt that the pathogenesis part of the disease is much more interesting (and may be can be given a more detailed treatment). I'm sorry that apart from the "Bile duct" section, I haven't been able to concentrate on this article. That's mostly because of shoulder dystocia and articles related to childbirth that are in a terrible state (much worse than even lymphatic system considering their importance in the medical field. Was trying to set them right. Hope you don't mind that. But, will certainly return to this article, too. I'll be able to comment upon the current state of the article only after I'm told what level of details are expected of this article.


 * Somehow, I also felt that since this disorder is so intimately related to choledocholithiasis, pathogenesis and risk factors for that should also find some mention in this article, otherwise this article has very little of "its own" pathogenesis to write about.


 * Regards.  —Ketan Panchal t aL K  09:23, 17 June 2008 (UTC)

Hey JFW, the article does seem to have got a lot better over the last 24 hours or so. Here my thoughts about the atricles present state. Some of it might be nitpicky. Hopefully it helps.

Intro is pretty good. These are the things i thought could be added:
 * cholangitis - derivation (i think its classical greek) ✅
 * characteristic symptoms - since its only 15-20% should we mention that it is not often seen making it difficult to diagnose.
 * Can't find a source that specifically says that the diagnosis is difficult. The general clue is "fever/infection + obstructive LFTs = cholangitis". JFW | T@lk  20:15, 17 June 2008 (UTC)

Diagnoses:
 * A bit hard to understand. The bit about LFT's will be constant with obstruction might not make sense to the general audience as the article does not mention obstruction before this. ✅
 * I think pathogenesis should come before diagnoses as it will help understand whats mentioned in the later sections.
 * I tend to resist the temptation, as the intro covers most points, but I'm open to persuation & consensus. JFW | T@lk  20:15, 17 June 2008 (UTC)

Pathogenesis:
 * Bile cannaliculi doesn't need to be mentioned ✅
 * Before mentioning that duodenum is a source of bacteria, mention that in ascending cholangitis bacteria migrate upwards. Then provide theories for the origin of the bacteria. ❌ - see above JFW | T@lk  20:15, 17 June 2008 (UTC)
 * I think perhaps the bit about partial obstruction causing bacteria to migrate upwards should be expaliend better if possible. (Why does partial obstruction force it to go upwards?)

Treatment
 * Empirical treatment(i'm not to sure whats it means in the given context)
 * This is evident from the context; the remainder of the sentence makes it clear that empiricial means "guesswork"
 * It would be nice to explain what a nasobilary drain is as people might not no what a nasograstic tube is. But i guess they can check the nasogastric tube article. ✅
 * "findings on other imaging studies" should it be "other findings on imaging studies."? ❌ ERCP is technically also an imaging study JFW | T@lk  20:15, 17 June 2008 (UTC)
 * bit about blood clotting needs a bit of rephrasing to make it sound better. (took me while to understand what was going on) ✅

But thanks for all the work thats been done so far. I'll try add some stuff as well. Ziphon (ALLears) 12:21, 17 June 2008 (UTC)

Short comment
I don't know if my threshold would be considered low, but, I believe the article is in a very good shape now. May be we can elaborate a bit on pathogenesis, (and hence, the risk factors) of this condition as well as the gallstones. Congratulations to JFW!

Regards.

PS: I am making this comment after going carefully through the entire article.

 —Ketan Panchal t aL K  11:13, 17 June 2008 (UTC)
 * I'd agree it's looking a lot better now due to the work both you and Jfdwolff have put into it! I'd say it's probably a B class now, needs a bit more work before becoming GA, though :) Regards, CycloneNimrod talk? contribs? 15:06, 17 June 2008 (UTC)


 * GA? We've only been going for two days! I'm sure that with some ongoing improvements we'll reach GA in the course of next week, but I need you guys to double-check my edits and make suggestions for improvements. JFW | T@lk  20:17, 17 June 2008 (UTC)
 * Haha, JFW I wasn't suggesting we put it up for a nom now ;) Of course it needs more work. I'll try and get working on this soonish. Regards, CycloneNimrod talk? contribs? 20:24, 17 June 2008 (UTC)

another article
I've found another journal article(its not free). It has some additional information on risks and data about what % of cholangitis is caused by tumours. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines I'll try add any relevant information in it.Ziphon (ALLears) 08:00, 18 June 2008 (UTC)


 * Yeah, the Tokyo guidelines are part of a whole series of articles. The problem is that the article is also not free, and it reflects on pracice in Japan where bile duct stones often do not originate from the gallbladder but develop in situ for some reason. JFW | T@lk  08:23, 18 June 2008 (UTC)


 * The good thing is that SpringerLink displays all the references! We might be able to snatch the more important ones (e.g. the ones reporting mortality in cholangitis). JFW | T@lk  08:25, 18 June 2008 (UTC)


 * Such as, , . JFW | T@lk  08:30, 18 June 2008 (UTC)

The article mentions that "Choledocholithiasis used to be the most frequent cause of the obstruction, but recently, the incidence of acute cholangitis caused by malignant disease, sclerosing cholangitis, and non-surgical instrumentation of the biliary tract has been increasing. It is reported that malignant disease accounts for about 10%–30% of cases of acute cholangitis." This information is based on results from studies at the university of paris,john hopkins hospital USA, university of rome, and a questionaire through japan. Ziphon (ALLears) 08:43, 18 June 2008 (UTC)


 * Feel free to add this. Perhaps a new section called "Causes". JFW | T@lk  09:47, 18 June 2008 (UTC)


 * I have moved the addition to a section called "causes" and changed it to prose. Bulleted lists are generally discouraged (see MOS). JFW | T@lk  10:03, 18 June 2008 (UTC)


 * Could I ask you to write a "prognosis" paragraph? Having reviewed the three papers above I think it would be more useful to cite the conclusions from the Tokyo paper on mortality predictors of poor outcome. JFW | T@lk  10:07, 18 June 2008 (UTC)
 * ✅ Does it look alright Ziphon (ALLears) 12:35, 18 June 2008 (UTC)


 * Perfect. I've made some pedantic changes :-). Perhaps we ought to clarify the meanings of respiratory failure, myocardial ischaemia etc. JFW | T@lk  14:45, 18 June 2008 (UTC)

Great work JFW
Excellent work JFW as usual! One thing... the cholangiogram clearly shows a naso-biliary drain so it's technically not an ERCP. I will work on the article when I get a chance. JC Petit 05:57, 20 June 2008 (UTC)


 * Kinney doesn't mention this use of a nasobiliary drain. Have you got another source? JFW | T@lk  09:20, 20 June 2008 (UTC)


 * The drain was probably put in prior to ESWL of the large stone (the cholangiogram shows a monster of a stone for which mechanical lithotripsy would be challenging). You can't see most stones on ultrasound prior to ESWL, so you leave a nasobiliary drain to do a cholangiogram in order to target the stone. JC Petit 04:32, 22 June 2008 (UTC)


 * Can I also give a significant chunk of the credit to Ziphon and KC Panchal? JFW | T@lk  11:40, 20 June 2008 (UTC)
 * Of course. The article looks brilliant, everyone did a fabulous job. JC Petit 04:32, 22 June 2008 (UTC)

A few more changes
I have made a few changes, particularly expanded the section on "pathogenesis" and added a few notes in "treatment". I have changed the section heading "cholangitis" to "definitive treatment" as I also had to add a note on prevention in those with stents.

Do let me know if these changes are agreeable.

I'm not sure if there's much greater scope for expansion ; may be there is for improvement, but not expansion.

Also, I have created a page Acute cholangitis, which redirects to Ascending cholangitis. That should be alright I suppose.

 —Ketan Panchal t aL K  13:29, 20 June 2008 (UTC)


 * While, I have no problem with having a separate heading for "cholecystectomy", I could not think of a proper title for the first and the last paragraphs in the section:


 * "The treatment mentioned above is largely targeted towards warding of immediate danger to life and does not counter the underlying cause (obstruction and bacterial contamination), which would require definitive treatment."


 * Not all gallstones implicated in ascending cholangitis actually originate from the gallbladder, but cholecystectomy (surgical removal of the gallbladder) is generally recommended in people who have been treated for cholangitis due to gallstone disease. This is typically delayed until all symptoms have resolved and ERCP or MRCP have confirmed that the bile duct is clear of gallstones.


 * "Continual contamination of bile duct by indwelling stents (as may occur in chronic conditions like tumor of the head of pancreas) requires monitoring by repeated radiologic tests and changing of the stents."


 * They (the two paragraphs) are seeming very much out of context (in that section) even though, they are not at all irrelevant to the topic. That's why I'd made that change. Also, a separate subsection for just two lines wasn't seeming appropriate as well. Well, now I have made some change. Am not sure if that's the best solution.


 *  —Ketan Panchal t aL K  14:08, 20 June 2008 (UTC)

A to Z
Interesting to see that the Kinney article has been already cited so many times that the reference section has exhausted the entire alphabet. Hope we don't have to cite it one more time!  —Ketan Panchal t aL K  14:18, 20 June 2008 (UTC)


 * Hmm. I'll have no qualms citing it again if needed. It is a rather good article for our purposes. JFW | T@lk  14:54, 20 June 2008 (UTC)


 * It's okay, we still have plenty of characters left for use if we decide to cite it more ;) Regards, CycloneNimrod talk? contribs? 17:51, 20 June 2008 (UTC)

Duplication
Due to the use of ERCP as a diagnostic as well as a therapeutic modality, there is presently some overlap wrt description of this technique. I have no real problems with this, but it may warrant some reshuffling. JFW | T@lk  06:41, 22 June 2008 (UTC)

When to go for GA
After JC Petit's expert expansion of the "treatment" section (I totally forgot to mention lithotrypsy) I am convinced that we ought to submit this baby for WP:GAC before the end of the MCOTW cycle. JFW | T@lk  06:41, 22 June 2008 (UTC)
 * In my (very limited) experience, an article takes correct direction towards finer improvements only after being nominated. So, we can nominate it. As it is, right now quite a few users are concentrating on the article&mdash;Ziphon, JC, Cyclonenim, yourself, and myself&mdash;so as and when recommendations are made, we can make appropriate corrections (almost round the clock). So, I think we can indeed nominate it at the earliest (may be even right now).  —Ketan Panchal t aL K  10:41, 22 June 2008 (UTC)

Fine then - GAN it is. JFW | T@lk  11:57, 22 June 2008 (UTC)
 * All the best and thanks!  —Ketan Panchal t aL K  14:42, 22 June 2008 (UTC)

Dr Kinney says hi
I asked Dr Kinney to have a look at our current version. He was very positive, and only made the following remark:


 * The one comment i would make is that under the treatment section, you discuss antibiotics as the primary therapy, and suggest that "The above treatment may prove ineffective in about 15% cases." Drainage via ERCP is really the primary treatment and antibiotics are used to temporize and treat any systemic complication of infection.  While antibiotics are of course used, they are secondary to drainage as the primary therapy.

I will try to revise this today, probably using his own review. JFW | T@lk  06:38, 23 June 2008 (UTC)


 * That's certainly very encouraging. So, we're on the right track.  —Ketan Panchal t aL K  10:57, 23 June 2008 (UTC)


 * ✅ I have rephrased a sentence or two. JFW | T@lk  17:57, 23 June 2008 (UTC)

Cancer risk
10.1136/gutjnl-2013-305039 is a primary study suggesting that cholangitis is a strong predictor of upper gastrointestinal malignancy within the next 6 months. We're going to see this is secondary sources soon. JFW &#124; T@lk  11:50, 31 December 2013 (UTC)