PERICHOLANGITIS

1. Chief complaint

•Pericholangitis

2. HPI
a. Concern:
b. Onset-
•Sudden
•Gradual

c. Duration: ____
•Recent
•A few days
•Many days
•A few weeks
•Many weeks
•A few months
•Many months
•A few years
•Many years
•Recurrent
•N/A.

d. Severity:
•Mild
•Moderate
•Severe
•Absent
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit.
•Details

e. Location: Right upper quadrant

f. Radiation:
•The flanks
•Intrascapular regions
 •Right shoulder

g. Quality:
•Improving
•No change
•Worsening
•Burning pain
•Constricting
•Crushing
•Dull pain
•Heavy
•Sharp pain
•Squeezing
•Stabbing

h. Frequancy
i. Status
j. Context
k. Aggravated by :
l. Relieved by
m. Associated Symptoms
n. Pertinent Negatives
o. Notes

3. ROS
4. SYMPTOMS

•Fever
•Jaundice
•Abdominal pain

5. HISTORY

a. FAMILY HISTORY
b. SOCIAL HISTORY
c. PAST MEDICAL HISTORY
•IBD
d. SURGICAL HISTORY
e. CHRONIC CONDITIONS
•IBD

6. ALLERGIES
 7. PHYSICAL EXAMINATION

Abnormal physical findings

•Jaundice
•Hepatomegaly
•Splenomegaly
•Ascites and edema
•Spider angiomata
•Leukonychia
•Muscle wasting
•Gynecomastia
•Testicular atrophy
•Palmar erythema
•Excoriations due to pruritus
8. SPECIFIC DATA LIKE GRADING

Pericholangitis is staged from 1-4 based on histologic findings.

•Stage 1 (portal stage)

o Lymphocytic portal inflammation is accompanied by
variable amounts of edema, fibrosis, and bile ductular
proliferation.
o Most ducts are without abnormality, but some show
degenerative changes, periductal fibrosis, and
nonsuppurative fibrous cholangitis (the typical "onion skin
lesion" of PSC).

•Stage 2 (periportal stage)

o Periportal fibrosis with or without periportal hepatitis and
expansion of the portal triads with seemingly intact newly
formed limiting plates occurs.
o Focal ductopenia often is noted in this stage.

•Stage 3 (septal stage)

o Septal fibrosis and/or bridging necrosis are prominent.
o Bile ducts often are severely damaged or absent.
o Other features include piecemeal necrosis and prominent
copper deposition.

•Stage 4 (cirrhotic stage)

o The liver is cirrhotic, and bile ducts often have
disappeared.
 o At this stage, differentiation from other cholestatic liver
diseases, particularly PBC, may be difficult.

9. TESTS TO BE ORDERED

•Alanine aminotransferase
•Alkaline phosphatase
•Aspartate aminotransferase
•Gamma-glutamyl transpeptidase
•Serum bilirubin
•Prothrombin time
•Albumin
•Perinuclear antineutrophil cytoplasmic antibody
•Antimitochondrial antibody
•Antinuclear antibodies (ANA)
•smooth muscle antibodies (SMA)
•X-ray abdomen
•Abdominal ultrasonography
•CT scan
•MRI
•Magnetic resonance cholangiopancreatography
•Hepatitis serology
•Endoscopic retrograde cholangiopancreatography
•Liver biopsy

10. ASSESSMENT/PLAN
•Liver transplantation

11. EDUCATION
• Take fat-soluble vitamins (ie, A, D, E, and K).
• Take calcium (>1000 mg/d) and vitamin D (800 IU/d).
• Take bisphosphonate therapy.
12. MEDICATION

•Ursodiol

13. FOLLOW UP