Clinical Commander

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gi.acute-cholangitis.core.v1

Acute Cholangitis

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch23 SCAFFOLD only (defineBatch23ScaffoldManifest with single sourceWorkupId acute_cholangitis); no phenotypes/red-flags/medications/dosing authored. Problem-package at src/lib/tier3/problem-package/packages/acute-cholangitis/ exists with full atom set, but no `_design-brief.md` and the engine-side manifest is a stub. Workup `acute_cholangitis` is registered in clinical-tools-registry (TG18). No engine-specific calculators; calc.qsofa borrowed for sepsis screen. Gaps: full evidence reconciliation needed (TG18 + ACG cholangitis); empty terminology arrays (codes live in workup adapter); regimen_axes empty (pip-tazo, ceftriaxone+metronidazole, meropenem need RxCUI verification); no design brief; no dedicated test_files.

Entry points (4)

  • symptom
    Charcot triad — fever + RUQ pain + jaundice (ACG 2024)
    charcot_triad
  • symptom
    Reynolds pentad — Charcot + AMS + shock (ACG 2024)
    reynolds_pentad
  • lab_abnormality
    Cholestatic LFTs (ALP/GGT/bilirubin elevated) (ACG 2024)
    cholestatic_lfts
  • imaging
    CBD dilation / choledocholithiasis on imaging (ACG 2024)
    cbd_dilation

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    TG18 severity adjusts thresholds; geriatric mortality risk (ACG 2024)
  • temperaturerequired
    vital • used at CONTEXT
    Fever/chills core to Charcot triad (ACG 2024)
  • sbprequired
    vital • used at CONTEXT
    Hypotension defines TG18 Grade III; sepsis screen (ACG 2024)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia for SIRS/sepsis (ACG 2024)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis + organ dysfunction stratifies TG18 grade (ACG 2024)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Cholestatic injury marker; TG18 diagnostic component (ACG 2024)
  • alprequired
    lab • used at INITIAL_WORKUP
    Cholestatic pattern confirmation (ACG 2024)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal organ dysfunction (TG18 III); contrast/abx dosing (ACG 2024)
  • lactate
    lab • used at RED_FLAGS
    Severity marker — sepsis / hypoperfusion (ACG 2024)
  • ruq_usrequired
    imaging • used at INITIAL_WORKUP
    First-line — CBD dilation, stones (ACG 2024)
  • mrcp
    imaging • used at BRANCHING_WORKUP
    Non-invasive ductal anatomy when US equivocal (ACG 2024)
  • prior_biliary_surgery
    history • used at CONTEXT
    Anatomy alters ERCP feasibility (ACG 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm acute biliary sepsis scope; differentiate from acute cholecystitis without ductal obstruction (ACG 2024)
    inputs: age
    advance: biliary obstruction + infection plausible
  2. 2ENTRY
    Recognize Charcot/Reynolds pentad or cholestatic LFT abnormality (ACG 2024)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, prior biliary surgery, anticoagulation, comorbidities, allergies (ACG 2024)
    inputs: temperature, sbp, hr, prior_biliary_surgery
    advance: context captured
  4. 4RED_FLAGS
    Reynolds pentad (shock + AMS), TG18 Grade III organ dysfunction, suppurative cholangitis (ACG 2024)
    inputs: sbp, lactate
    actions: calc.qsofa
    advance: shock identified or excluded
  5. 5INITIAL_WORKUP
    CBC, LFT (ALP/bilirubin/GGT/AST/ALT), BMP, lactate, blood cultures x2, RUQ ultrasound (ACG 2024)
    inputs: wbc, total_bilirubin, alp, creatinine, ruq_us
    actions: panel.lft, panel.cbc, panel.renal
    advance: labs + US obtained
  6. 6BRANCHING_WORKUP
    MRCP if US non-diagnostic; CT if abscess/perforation; EUS for distal CBD stones (ACG 2024)
    inputs: mrcp
    actions: acute_cholangitis
    advance: biliary obstruction characterised
  7. 7DIFFERENTIAL
    Confirm cholangitis vs acute cholecystitis, hepatic abscess, viral hepatitis, pancreatitis (ACG 2024)
    advance: differential resolved
  8. 8RISK_STRATIFICATION
    TG18 severity grade I / II / III; sepsis screen (ACG 2024)
    inputs: wbc, creatinine
    actions: calc.qsofa
    advance: TG18 grade assigned
  9. 9TREATMENT
    Empiric IV antibiotics + biliary drainage (ERCP first-line; PTBD if ERCP not feasible) within 24h for moderate-severe (ACG 2024)
    inputs: creatinine
    advance: antibiotics started + drainage plan in motion
  10. 10DISPOSITION
    ICU for Grade III; floor for Grade I-II; ERCP/IR scheduling (ACG 2024)
    inputs: sbp
    advance: destination + procedure timing locked
  11. 11MONITORING
    Serial vitals, daily LFT trend, lactate clearance, response to drainage (ACG 2024)
    inputs: total_bilirubin, lactate
    advance: response documented or escalated
  12. 12FOLLOWUP
    Interval cholecystectomy after stone-related cholangitis; LFT normalization; recurrence counseling (ACG 2024)
    advance: follow-up scheduled