Preliminary Diagnosis: Ascending Cholangitis
I. What imaging technique is first-line for this diagnosis?
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Ultrasound of the biliary tree.
II. Describe the advantages and disadvantages of this technique for diagnosis of Ascending Cholangitis.
Advantages
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Highly portable imaging modality.
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Does not expose patients to ionizing radiation.
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May help guide percutaneous intervention and biopsy that will help clinch diagnosis of ascending cholangitis.
Disadvantages
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Highly operator dependent.
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Limited in evaluating the surrounding soft tissues.
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Ascending cholangitis diagnosis is clinched with a histological diagnosis.
III. What are the contraindications for the first-line imaging technique?
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No specific contraindications to sonographic imaging exist.
IV. What alternative imaging techniques are available?
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Magnetic resonance cholangiopancreatography (MRCP).
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CT imaging.
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Cholangiography.
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Endoscopic retrograde cholangiopancreatography (ERCP).
V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of Ascending Cholangitis.
MRCP
Advantages
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Offers exquisite visualization of the intrahepatic and extrahepatic biliary tree.
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Does not expose patients to ionizing radiation.
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May be performed without contrast in patients who cannot receive contrast medium.
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Diagnostic imaging modality.
Disadvantages
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May be subject to motion and susceptibility weighted imaging, degrading image quality.
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Less sensitive to mineralized and air densities.
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Expensive.
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Time-consuming..
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Ascending cholangitis is a histological diagnosis.
CT imaging
Advantages
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Offers exquisite visualization of the surrounding soft tissues, osseous structures, and vasculature.
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Highly sensitive to mineralized and air densities often present in the biliary system.
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May help guide percutaneous intervention and treatment.
Disadvantages
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Exposes patients to ionizing radiation.
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Ascending cholangitis is a histological diagnosis.
Cholangiography
Advantages
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Offers both diagnostic and therapeutic capabilities simultaneously.
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Offers the ability for histological diagnosis and imaging diagnosis to be done simultaneously.
Disadvantages
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Highly operator dependent.
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Exposes patients to increased morbidity and mortality from being an invasive procedure.
Endoscopic retrograde cholangiopancreatography (ERCP)
Advantages
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Gold standard in diagnosing and treating ascending cholangitis.
Disadvantages
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May not be available at all institutions as ERCP must be performed by trained gastroenterology specialists.
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Risk for trauma to common bile duct and pancreatic duct from procedure.
VI. What are the contraindications for the alternative imaging techniques?
MRCP
May be contraindicated in patients with non-MR compatible hardware.
CT imaging
May be contraindicated in pregnant patients.
Cholangiography
Contraindicated in patients in a severe hypocoagulable state.
ERCP
Contraindicated in patients in a severe hypocoagulable state.
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