Biliary EmergenciesBiliary EmergenciesMurad Aljiffry Murad Aljiffry MD FRCSCMD FRCSC

Case 1Case 1

61 year old male61 year old male Abdominal pain for 5 days Associated with: Fever, malaise, chest pain with

shortness of breath and anorexia Past Hx.: diverticulitis treated Physical examination

HR 120, B/P 100/60 Localized RUQ peritoneal findings

Case 1Case 1

Lab: WBC: 18, Hb: 10, Creat 130, T.bili 60, ALP 350, Alb 25

US: Hypoechoic liver lesion with

thickened irregular wall Gall stones

What next?

Case 1Case 1

Abdominal CT (contrast-enhanced) Hypodense lesion of left

lobe(5.5cm) occupies segment II and III

well demarcated, round

Liver AbscessLiver Abscess

Pyogenic(80%): E. coli, K.PPyogenic(80%): E. coli, K.P Paracytic(10%): Entamaeba Paracytic(10%): Entamaeba

histolyticahistolytica Others(10%): candidaOthers(10%): candida

EpidemiologyEpidemiology

Incidence in the US is 8-15 per Incidence in the US is 8-15 per 100,000100,000

Male to female ratio is 2:1 in Male to female ratio is 2:1 in recent studiesrecent studies

55thth-7-7thth decades of life decades of life Risk factors : DM, underlying Risk factors : DM, underlying

hepatobiliary or pancreatic hepatobiliary or pancreatic malignancy, and liver transplantmalignancy, and liver transplant

EtiologyEtiology

Biliary disease accounts for 20-Biliary disease accounts for 20-40% 40%

Extrahepatic obstruction leading Extrahepatic obstruction leading to ascending cholangitis and to ascending cholangitis and abscessabscess CBD stonesCBD stones Benign and malignant tumorsBenign and malignant tumors Biliary enteric anastamoses or Biliary enteric anastamoses or

manipulationmanipulation

EtiologyEtiology

Infection via portal systemInfection via portal system Infectious process originates in Infectious process originates in

abdomen, reaches liver by abdomen, reaches liver by embolization through portal embolization through portal systemsystem

Appendicitis, diverticulitis, IBD, Appendicitis, diverticulitis, IBD, proctitisproctitis

EtiologyEtiology

Hematogenous via hepatic arteryHematogenous via hepatic artery From systemic septicemia such From systemic septicemia such

as endocarditis and as endocarditis and pyelonephritis pyelonephritis

Direct extension or traumaDirect extension or trauma No cause (cryptogenic) in 20-No cause (cryptogenic) in 20-

40% of cases40% of cases

EtiologyEtiology

Underlying etiology of 1086 cases of liver abscess compiled Underlying etiology of 1086 cases of liver abscess compiled from the literature from the literature

MicrobiologyMicrobiology

Most contain more than one organismMost contain more than one organism Blood cultures positive in 33-65%Blood cultures positive in 33-65% E.Coli E.Coli Klebsiella (Klebsiella (is an important emerging is an important emerging

infection infection associated with associated with endophthalmitis )endophthalmitis )

BacteroidesBacteroides Streptococcal (including S. aureus and Streptococcal (including S. aureus and

S. pyogenes)S. pyogenes) Candida species : usually occurs in Candida species : usually occurs in

immunosuppressedimmunosuppressed patients patients

MicrobiologyMicrobiology

Microbiologic results from 312 cases of liver abscess compiled from the literature

ClinicalClinical

Fever (85-100%), abdominal pain Fever (85-100%), abdominal pain (50-75%)(50-75%)

About one-half of patients with About one-half of patients with liver abscess have liver abscess have hepatomegaly, RUQ tenderness, hepatomegaly, RUQ tenderness, or jaundice or jaundice

Right shoulder pain, pleuritic Right shoulder pain, pleuritic chest painchest pain

Anorexia, weight loss, mental Anorexia, weight loss, mental confusionconfusion

Diagnosis-LabDiagnosis-Lab

CBC: anemia in 50-80%, CBC: anemia in 50-80%, leukocytosis in 75-96%leukocytosis in 75-96%

LFTs: elevated alkaline LFTs: elevated alkaline phosphatase 95-100%, elevated phosphatase 95-100%, elevated AST, ALT 40-60%AST, ALT 40-60%

Elevated bilirubin in 20-50%Elevated bilirubin in 20-50% Decreased albumin in 71-87%Decreased albumin in 71-87%

Diagnosis-ImagingDiagnosis-Imaging

CT and ultrasound are the CT and ultrasound are the modalities of choice (80-100% modalities of choice (80-100% sensitive)sensitive)

An abscess appears An abscess appears radiologically as a fluid collection radiologically as a fluid collection with surrounding edema and with surrounding edema and inflammation (rim enhancement) inflammation (rim enhancement) that may contain loculated that may contain loculated subcollections and gassubcollections and gas

TreatmentTreatment

Initiation of antibiotic therapyInitiation of antibiotic therapy Diagnostic aspiration and Diagnostic aspiration and

drainage of abscessdrainage of abscess Surgical drainage in selected Surgical drainage in selected

patientspatients

Antibiotic TherapyAntibiotic Therapy

Empiric broad-spectrum antibiotics Empiric broad-spectrum antibiotics (draw blood culture before)(draw blood culture before)

A third generation cephalosporin A third generation cephalosporin such as ceftriaxone + metronidazolesuch as ceftriaxone + metronidazole

Fluoroquinolone (eg, ciprofloxacin) + Fluoroquinolone (eg, ciprofloxacin) + metronidazolemetronidazole

Monotherapy with a carbapenem or Monotherapy with a carbapenem or an extended spectrum penicillinan extended spectrum penicillin

Antibiotic TherapyAntibiotic Therapy

Immunocompromised patients Immunocompromised patients with multiple abscesses are best with multiple abscesses are best treated with high dose antibiotics treated with high dose antibiotics rather than open or rather than open or percutaneous drainagepercutaneous drainage

DrainageDrainage

For single abscesses with diameter ≤5 For single abscesses with diameter ≤5 cm : cm : percutaneous catheter drainage or needle percutaneous catheter drainage or needle

aspiration is acceptable (usually multiple)aspiration is acceptable (usually multiple) For single abscesses with diameter >5 For single abscesses with diameter >5

cm :cm : Percutaneous management (catheter Percutaneous management (catheter

drainage no needle aspiration)drainage no needle aspiration) Some favor surgical intervention over Some favor surgical intervention over

percutaneous drainage, treatment failure percutaneous drainage, treatment failure lower with surgical drainagelower with surgical drainage

Success 70-90%Success 70-90%

Complications of Complications of Percutaneous Percutaneous

DrainageDrainage Perforation of a viscousPerforation of a viscous PneumothoraxPneumothorax BleedingBleeding Leakage of pus into the abdomenLeakage of pus into the abdomen

Surgical TherapySurgical Therapy

Indications of surgical drainage:Indications of surgical drainage: Co-existing intra-abdominal disease Co-existing intra-abdominal disease

that requires operative managementthat requires operative management Failure of percutaneous drainageFailure of percutaneous drainage Multiple abscesses Multiple abscesses Loculated abscesses Loculated abscesses Abscesses with viscous contents Abscesses with viscous contents

obstructing the drainage catheterobstructing the drainage catheter Ascites or coagulopathyAscites or coagulopathy

Surgical TherapySurgical Therapy

Transthoracic, extraperitoneal, Transthoracic, extraperitoneal, transperitonealtransperitoneal

Transperitoneal is preferred as Transperitoneal is preferred as intra-abdominal pathology can intra-abdominal pathology can be dealt withbe dealt with

Laparoscopic or openLaparoscopic or open

Duration of therapy Duration of therapy 

Follow imaging, WBC count and Follow imaging, WBC count and serum CRPserum CRP

Drainage catheters should Drainage catheters should remain in place until drainage is remain in place until drainage is minimal minimal

Patients should be treated for 2-4 Patients should be treated for 2-4 weeksweeks

ComplicationsComplications

Result from rupture of abscess Result from rupture of abscess into adjacent organs or cavitiesinto adjacent organs or cavities

Pleuropulmonary include Pleuropulmonary include effusions, empyema, bronch-effusions, empyema, bronch-hepatic fistulahepatic fistula

Intraabdominal include Intraabdominal include subphrenic abscess, rupture into subphrenic abscess, rupture into peritoneal cavity, or any peritoneal cavity, or any intraabdominal organintraabdominal organ

PrognosisPrognosis

Mortality rate : 10- 20%Mortality rate : 10- 20% If untreated fatal (100% mortality If untreated fatal (100% mortality

rate)rate) Mortality appears to be related to Mortality appears to be related to

underlying comorbidities rather than underlying comorbidities rather than to the abscess itselfto the abscess itself

Poor prognosis: age >70, multiple Poor prognosis: age >70, multiple abscesses, polymicrobial infection, abscesses, polymicrobial infection, immunosupression, malignancy, and immunosupression, malignancy, and delay diagnosisdelay diagnosis

Questions?Questions?

Case 2Case 2

40 y.o. female presents to ER 40 y.o. female presents to ER with 12 hr history of upper with 12 hr history of upper abdominal pain and feverabdominal pain and fever

Associated nausea and vomitingAssociated nausea and vomiting Lab: wbc 12, AST100, ALT220, Lab: wbc 12, AST100, ALT220,

GGT1400, ALP 1340, Tbili 75GGT1400, ALP 1340, Tbili 75

Case 2Case 2

Amylase and Lipase slight Amylase and Lipase slight elevationelevation

U/S – multiple small stones in U/S – multiple small stones in gallbladder, CBD9mm, no gallbladder, CBD9mm, no intrahepatic dilatationintrahepatic dilatation

What next?What next?

Case 2Case 2

H/O gastric bypassH/O gastric bypass 2:00 am2:00 am

Acute CholangitisAcute Cholangitis

Pus under pressurePus under pressure May be difficult to distinguish May be difficult to distinguish

from acute cholecystitisfrom acute cholecystitis Managed medically with support, Managed medically with support,

antibioticsantibiotics Drainage is keyDrainage is key

EtiologyEtiology

Stone diseaseStone disease Anomalous PBJAnomalous PBJ Malignant biliary obstructionMalignant biliary obstruction Primary sclerosing cholangitisPrimary sclerosing cholangitis Post instrumentationPost instrumentation

CholangiographyCholangiography SurgerySurgery SphincterotomySphincterotomy StentsStents

MicrobiologyMicrobiology

80% patients +ve biliary cultures 80% patients +ve biliary cultures (multiple organisms frequent )(multiple organisms frequent ) E.Coli (commonest)E.Coli (commonest) Enterococci Enterococci Klebsiella spKlebsiella sp Proteus spProteus sp Pseudomonas spPseudomonas sp Bacteroides spBacteroides sp

Clinical PresentationClinical Presentation

Charcot’s triadCharcot’s triad Pyrexia, Pain, JaundicePyrexia, Pain, Jaundice

Elevated liver enzymesElevated liver enzymes LeukocystosisLeukocystosis

DiagnosisDiagnosis

Clinical Clinical UltrasoundUltrasound

Duct dilationDuct dilation Presence of gallbladder or CBD stonesPresence of gallbladder or CBD stones

CTCT Duct dilationDuct dilation R/O other causesR/O other causes

MRCP (especially for hilar obstruction, MRCP (especially for hilar obstruction, if stable pt.)if stable pt.)

ERCP (generally for therapy)ERCP (generally for therapy)

ManagementManagement

Fluid resuscitation Triage (floor or ICU) Correction of coagulopathy and

electrolytes Blood cultures Antibiotics (broad spectrum)

ManagementManagement

Most pt will respond and will require urgent biliary decompression

10-15% of patients fail to respond or deteriorate within 12-24 hours, thus require emergent biliary decompression

Biliary DrainageBiliary Drainage

EndoscopicEndoscopic SurgicalSurgical PercutaneousPercutaneous

Endoscopic Biliary Endoscopic Biliary DrainageDrainage

Can be done at bedside in ICU with Can be done at bedside in ICU with portable flouroscopyportable flouroscopy

Superior to surgical drainageSuperior to surgical drainage Mortality of endoscopic vs surgical Mortality of endoscopic vs surgical

drainage 10% vs 32% RCT (Lai NEJM drainage 10% vs 32% RCT (Lai NEJM 1992)1992)

Preferable to percutaneous drainagePreferable to percutaneous drainage Morbidity less (Sugiyama Arch Surg 1997, Morbidity less (Sugiyama Arch Surg 1997,

AmJGastro 1998)AmJGastro 1998) Especially in presence of ascites, Especially in presence of ascites,

coagulopathycoagulopathy

Endoscopic Biliary Endoscopic Biliary DrainageDrainage

SphincterotomySphincterotomy Caution due to bleeding riskCaution due to bleeding risk

Stone removalStone removal StentStent

Percutaneous Biliary Percutaneous Biliary draindrain

When endoscopic drainage failsWhen endoscopic drainage fails Inaccessible papillaInaccessible papilla Roux-en-YRoux-en-Y HepatolithiasisHepatolithiasis Segmental cholangitis (complex Segmental cholangitis (complex

hilar tumor)hilar tumor)

Surgical Biliary drainSurgical Biliary drain

Last resort Last resort Decompression of biliary tree Decompression of biliary tree

and placement of T tubeand placement of T tube

Questions?Questions?