Talk:Ascending cholangitis/GA1

GA Review

I am currently reviewing "Ascending cholangitis" for "Good article" status. Axl (talk) 17:53, 2 July 2008 (UTC)

The journal titles in the references section are inconsistently formatted. Some have full stops (periods) after the abbreviations while others don't. Axl (talk) 18:19, 2 July 2008 (UTC)

 Done JFW | T@lk 22:26, 2 July 2008 (UTC)

From "Signs and symptoms": "Reynolds' pentad includes the findings of Charcot's triad with the presence of septic shock and mental confusion." What is the frequency of Reynolds' pentad? Axl (talk) 18:29, 2 July 2008 (UTC)

 Not done None of my reviews give an actual figure. JFW | T@lk 22:26, 2 July 2008 (UTC)

Okay, too bad. Axl (talk) 07:19, 3 July 2008 (UTC)

From "Diagnosis", "Blood tests": "In the early stages, however, pressure on the liver cells may be the main feature and the tests will resemble those in hepatitis, with elevations in alanine transaminase and aspartate transaminase." Is this really true? I'm reading "Oxford Textbook of Clinical Hepatology" and there's no mention of this. Unfortunately my hospital library doesn't stock "Gastrointestinal clinics of North America". Axl (talk) 18:25, 2 July 2008 (UTC)

 Done Kinney sources it to PMID 17127193. In my clinical experience this does indeed happen early in the cause of severe cholangitis. JFW | T@lk 22:26, 2 July 2008 (UTC)

From "Diagnosis", "Medical imaging": "Compared to ERCP (see below), this modality may show dilation of the bile duct and identifies 38% of bile duct stones; it is relatively poor at identifying stones further down the bile duct." This sentence is rather awkward and should be split.The first part of the sentence: "Compared to ERCP, this modality may show dilation..." doesn't really make sense. Axl (talk) 18:51, 2 July 2008 (UTC)

 Done Unnecessary awkwardness. JFW | T@lk 22:26, 2 July 2008 (UTC)

From "Diagnosis", "Medical imaging": "If other causes rather than gallstones are suspected, such as tumors, computed tomography and endoscopic ultrasound...." When I first read this, it seemed that CT and EUS are causes of cholangitis. Axl (talk) 18:58, 2 July 2008 (UTC)

 Done Agree this was convoluted. JFW | T@lk 22:26, 2 July 2008 (UTC)

The "Causes" section is inadequate. "Postoperative damage" is mentioned. However there should be more information about iatrogenic causes. As well as biliary surgery, ERCP and PTC themselves can cause cholangitis. There should also be some discussion about the use of prophylactic antibiotics. Axl (talk) 19:08, 2 July 2008 (UTC)

 Done Totally agree that ERCP-associated cholangitis needs discussion. I have sourced this to Williams (recommendation 4.2.11), which states this explicitly. JFW | T@lk 22:26, 2 July 2008 (UTC)

From "Pathogenesis": "The duodenum is relatively rich in bacteria also found in the large intestine." It is? The Oxford textbook states "The duodenum and jejunum contain only scant Gram-positive organisms under normal circumstances." Similarly from Gorbach & Taqabchali. Axl (talk) 19:34, 2 July 2008 (UTC)

 Done Mea culpa, I misread a line in Kinney. He says that in biliary obstruction, colonic organisms are common in the duodenum. I have simply removed the offending observation. JFW | T@lk 22:26, 2 July 2008 (UTC)

In "Pathogenesis", the pressure in the biliary system isn't mentioned. Huang discussed it: "The significance of biliary pressure in cholangitis", pmid: 4888283. Axl (talk) 19:44, 2 July 2008 (UTC)

Correction: The importance of the biliary pressure should be emphasized more, perhaps by placing the paragraph higher up. Also, the values of the pressure should be mentioned, as per Huang. [I can do this if necessary.] Axl (talk) 20:29, 2 July 2008 (UTC)

 Not done Could I leave this to you, Axl? I'm not sure what degree of emphasis you'd like. JFW | T@lk 22:26, 2 July 2008 (UTC)

Yes, I'll work on it this evening. Axl (talk) 07:21, 3 July 2008 (UTC)

In "Pathogenesis": "It is important in this mode of proposed pathogenesis that the obstruction be partial, and not complete as the latter would not allow the bacteria to ascend upward and contaminate the biliary tree." Reference 1 is quoted. Is there actually any evidence for this? Axl (talk) 19:51, 2 July 2008 (UTC)

 Done Kinney seems to be speaking from experience. Any sentence beginning with "it is important" needs revision anyway. I will remove it, because the remainder of the paragraph speaks for itself. JFW | T@lk 22:26, 2 July 2008 (UTC)

In "Pathogenesis": "systemic inflammatory response syndrome (SIRS) comprising fever, rigors, low blood pressure, and increased respiratory rate." SIRS comprises two of four features: fever (or low temperature), tachycardia, tachypnoea and extreme white cell count. Axl (talk) 20:32, 2 July 2008 (UTC)

 Not done The intention was not to reproduce the classical definition of SIRS. Do you think we should follow that definition? JFW | T@lk 22:26, 2 July 2008 (UTC)

As it currently stands, the sentence is misleading. Either use the correct definition, or don't try to define it at all (the link provides assistance for unfamiliar readers). Axl (talk) 07:32, 3 July 2008 (UTC)

 Done Sorted. JFW | T@lk 16:37, 3 July 2008 (UTC)

The caption for the picture in "Medical imaging" mentions a "nasobiliary drain". I can guess what this means, although I've never heard of it before. Axl (talk) 21:01, 2 July 2008 (UTC)

Kinney mentions it, and several other sources (e.g. PMID 16374853) attest to its use. Do you think the explanation is adequate? JFW | T@lk 22:26, 2 July 2008 (UTC)

As a stand-alone picture, many non-medical readers would not understand the meaning. It is only later in the article that "nasobiliary drain" is properly described. I'm hoping for a wikilink (to a stub) to assist unfamiliar readers. Axl (talk) 07:38, 3 July 2008 (UTC)

I'm not entirely sure if an article is needed for this. Couldn't the caption simply refer to the text? JFW | T@lk 18:24, 3 July 2008 (UTC)

From "Treatment", "Endoscopy": "PTC is not without complications" What complications? [Cholangitis is one.] Axl (talk) 21:15, 2 July 2008 (UTC)

 Not done Kinney gives an 80% morbidity and 15% mortality, but doesn't give a breakdown of exact complications (such as perforation/biliary peritonitis). I think given that need for PTC is relatively unusual, this should be spun out on the PTC page rather than here. JFW | T@lk 22:26, 2 July 2008 (UTC)

Okay, but I've changed the language in the sentence. Axl (talk) 07:34, 3 July 2008 (UTC)

From "Treatment", "Endoscopy": "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." There should be more information about stents and the need/timing of repeat tests and stent changes. Axl (talk) 21:17, 2 July 2008 (UTC)

 Not done Perhaps that content belongs on the article about stents rather than here. Apart from cholangitis, there are numerous other considerations that are best dealt with in the relevant article IMHO. JFW | T@lk 22:26, 2 July 2008 (UTC)

Not critical for "Good article" status, but should be a consideration for future improvement. Axl (talk) 07:40, 3 July 2008 (UTC)

From "Prognosis": "Reported mortality rates for acute cholangitis vary between 2.5% to 65%." That's a massive range. The reference indicates the range 10-30%. Axl (talk) 21:22, 2 July 2008 (UTC)

 Done Kimura gives that very wide range. However, after 1980 the range 10-30 is given. JFW | T@lk 22:26, 2 July 2008 (UTC)

The reference formatting needs to be standardized: use of last and first, initials, absence of et al, date format. Axl (talk) 21:32, 2 July 2008 (UTC)

 Doing... Will try to sort this out. I'm really not sure what the point is in using last and first. Could you clarify? JFW | T@lk 22:26, 2 July 2008 (UTC)

Reference 2 (Schwartz) uses last and first. The reference that I added (Sung) also has last and first, but I would be happy to change this to the predominant style. I'm not insisting that last and first should be used. Rather the style should be consistent throughout the references. Axl (talk) 07:24, 3 July 2008 (UTC)

 Done Sorry, makes sense. JFW | T@lk 16:36, 3 July 2008 (UTC)

GA pass

I have passed Ascending cholangitis for "Good article" status. It is well-written, accurate, neutral, stable and well-illustrated.

Notes for future improvement: -

A wikilink from "nasobiliary drain" in the image at the top of the "Diagnosis", "Medical imaging" section.

A couple of one-sentence paragraphs should be expanded: at the end of "Treatment" and "Endoscopy" sections.

The main reference is "Gastrointestinal endoscopy clinics of North America". This has low impact factor and is not the most easily accessible source. I'm sure that many of those references could be changed to more reliable and accessible sources.

Axl (talk) 18:51, 3 July 2008 (UTC)

Thanks Axl. With regards to the source I was actually surprised that there were no good reviews available on cholangitis. Kinney's article is quite rigorous, and all other recent reviews have appeared in similar journals. Thankfully we had Tokyo2007 and the recent BSG guideline to supplement the content. JFW | T@lk 21:03, 3 July 2008 (UTC)