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Cholangitis &Management of
CholedocholithiasisRuby Wang MS 3
Surg 300A
8/20/07
Content Case
Cholangitis Clinical manifestations Diagnosis Treatment
Diagnosis and management of choledocholithiasis Pre-operative Intra-operative Post-operative
Case HPI:
86 yo lady p/w 3-4 episodes of RUQ/mid-epigastric abdominal pain over the last year, lasting generally several hours, accompanied by occasional emesis, anorexia, and sensation of shaking chills.
ROS: negative otherwise PE:
VS: T 36.2, P98 , RR 18, BP 124/64 Abdominal exam significant for RUQ TTP
Labs AST 553, ALT 418. Alk Phos 466. Bilirubin 2.7 WBC 30.3
Imaging Abdominal US: multiple gallstones, no pericholecystic fluid,
no extrahepatic/intrahepatic/CBD dilatation
Introduction Cholangitis is bacterial infection superimposed on biliary obstruction
First described by Jean-Martin Charcot in 1850s as a serious and life-threatening illness
Causes Choledocholithiasis Obstructive tumors
Pancreatic cancer Cholangiocarcinoma Ampullary cancer Porta hepatis
Others Strictures/stenosis ERCP Sclerosing cholangitis AIDS Ascaris lumbricoides
Epidemiology Nationality
U.S: uncommon, and occurs in association with biliary obstruction and causes of bactibilia (s/p ERCP)
Internationally: Oriental cholangiohepatitis endemic in SE Asia- recurrent pyogenic
cholangitis with intrahepatic/extrahepatic stones in 70-80% Gallstones highest in N European descent, Hispanic populations, Native
Americans Intestinal parasites common in Asia
Sex Gallstones more common in
women M: F ratio equal in
cholangitis Age
Median age between 50-60 Elderly patients more likely
to progress from asymptomatic gallstones to cholangitis without colic
Pathogenesis Normally, bile is sterile due to constant flush,
bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duodenal reflux and ascending infection
ERCP or biliary stent insertion can disrupt the Sphincter of Oddi barrier mechanism, causing pathogeneic bacteria to enter the sterile biliary system.
Obstruction from stone or tumor increases intrabiliary pressure
High pressure diminishes host antibacterial defense- IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization.
Bacteria gain access to biliary tree by retrograde ascent
Biliary obstruction (stone or stricture) causes bactibilia E Coli (25-50%) Klebsiella (15-20%), Enterobacter (5-10%)
High pressure pushes infection into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%).
Adam.about.com
Gpnotebook.co.uk Pathology.med.edu
Clinical Manifestations
RUQ pain (65%) Fever (90%)
May be absent in elderly patients Jaundice (60%) Hypotension (30%) Altered mental status (10%)
Charcot’s Triad:Found in 50-70% of patients
Reynold’s Pentad:
Additional HistoryPruitus, acholic stoolsPMH for gallstones, CBD stones, Recent ERCP, cholangiogram
Additional Physical TachycardiaMild hepatomegaly
Diagnosis: lab values CBC
79% of patients have WBC > 10,000, with mean of 13,600 Septic patients may be neutropenic
Metabolic panel Low calcium if pancreatitis 88-100% have hyperbilirubinemia 78% have increased alkaline phosphatase AST and ALT are mildly elevated
Aminotransferase can reach 1000U/L- microabscess formation in the liver
GGT most sensitive marker of choledocholithiasis Amylase/Lipase
Involvement of lower CBD may cause 3-4x elevated amylase Blood cultures
20-30% of blood cultures are positive
Diagnosis: first-line imagingUltrasonography Advantage:
Sensitive for intrahepatic/extrahepatic/CBD dilatation CBD diameter > 6 mm on US associated with high prevalence of choledocholithaisis Of cholangitis patients, dilated CBD found in 64%,
Rapid at bedside Can image aorta, pancreas, liver Identify complications: perforation, empyema, abscess
Disadvantage Not useful for choledocholithiasis:
Of cholangitis patients, CBD stones observed in 13% 10-20% falsely negative - normal U/S does not r/o cholangitis
acute obstruction when there is no time to dilate Small stones in bile duct in 10-20% of cases
CT Advantages
CT cholangiograhy enhances CBD stones and increases detection of biliary pathology Sensitivity for CBD stones is 95%
Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscess Can visualize other pathologies- cholangitis: diverticuliits, pyelonephritis, mesenteric
ischemia, ruptured appendix Disadvantages
Sensitivity to contrast Poor imaging of gallstones
Med.virgina.edu
Soto et al. J. Roenterology. 2000
Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP) Advantage
Detects choledocholithiasis, neoplasms, strictures, biliary dilations Sensitivity of 81-100%, specificity of 92-100% of
choledocholithiasis Minimally invasive- avoid invasive procedure in 50% of patients
Disadvantage: cannot sample bile, test cytology, remove stone Contraindications: pacemaker, implants, prosthetic valves
Indications If cholangitis not severe, and risk of ERCP high, MRCP useful If Charcot’s triad present, therapeutic ERCP with drainage should
not be delayed.Endoscopic retrograde cholangiopancreatography (ERCP) Gold standard for diagnosis of CBD stones, pancreatitis, tumors,
sphincter of Oddi dysfunction Advantage
Therapeutic option when CBD stone identified Stone retrieval and sphincterotomy
Disadvantage Complications: pancreatitis, cholangitis, perforation of duodenum
or bile duct, bleeding Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%
Medical Treatment Resucitate, Monitor, Stabilize if patient unstable
Consider cholangitis in all patients with sepsis
Antibiotics Empiric broad-spectrum Abx after blood cultures drawn
Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily) Carbapenems: gram negative, enterococcus, anaerobes Levofloxacin (250-500mgIV qD) for impaired renal fxn.
- 80% of patients can be managed conservatively 12-24 hrs Abx
- If fail medical therapy, mortality rate 100% without surgical decompression: ERCP or open
- Indication: persistent pain, hypotension, fever, mental confusion
Surgical treatment Endoscopic biliary drainage
Endoscopic sphincterotomy with stone extraction and stent insertion
CBD stones removed in 90-95% of cases
Therapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression
Surgery Emergency surgery replaced by non-
operative biliary drainage Once acute cholangitis controlled, surgical
exploration of CBD for difficult stone removal Elective surgery: low M & M compared with
emergency survey If emergent surgery, choledochotomy carries
lower M&M compared with cholecystectomy with CBD exploration
Our case… Condition:
No acute distress, reasonably soft abdomen
ERCP attempted Duct unable to cannulate due to presence of duodenum diverticulum at
site of ampulla of Vater
Laparoscopic cholecystectomy planned Dissection of triangle of Calot Cystic duct and artery visualized and dissected Cystic duct ductotomy Insertion of cholangiogram catheter advanced and contrast bolused into
cystic duct for IOC
Intraoperative cholangiogram Several common duct filling defects consistent with stones Decision to proceed with CBD exploration
Choledocholithiasis
Choledocholithiasis develops in 10-20% of patients with gallbladder disease
At least 3-10% of patients undergoing cholecystectomy will have CBD stones Pre-op Intra-op Post-op
Pre-op diagnosis & management
Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP High risk (>50%) of choledocholithiasis:
clinical jaundice, cholangitis, CBD dilation or choledocholithiasis on ultrasound Tbili > 3 mg/dL correlates to 50-70% of CBD stone
Moderate risk (10-50%): h/o pancreatitis, jaundice correlates to CBD stone in 15% elevated preop bili and AP, multiple small gallstones on U/S
Low risk (<5%): large gallstones on U/S no h/o jaundice or pancreatitis, normal LFTs
Treatment: ERCP Surgery
Intra-op diagnosis and management Diagnosis: intraoperative cholangiography (IOC)
Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects.
Detect CBD stones Potentially identify bile duct abnormalities, including iatrogenic injuries Sensitivity 98%, specificity 94% Morbidity and mortality low
Treatment Open CBD exploration
Most surgeons prefer less invasive techniques Laparoscopic CBD exploration
via choledochotomy: CBD dilatation > 6mm via cystic duct (66-82.5%) CBD clearance rate 97% Morbidity rate 9.5% Stones impacted at Sphincter of Oddi most difficult to extract
Intraoperative ERCP
Early years: Open CBD exploration & Introduction of endoscopic
sphincterotomy 1889, 1st CBD exploration by Ludwig
Courvoisier, a Swiss surgeon Kocherization of duodenum and short
longitudinal choledochotomy Stones removed with palpation, irrigation
with flexible catheters, forceps, Completion with T-tube drainage For many years, this was the standard
treatment for cholecystocholedocholithiasis
1970s, endoscopic sphincterotomy (ES) Gained wide acceptance as good, less
invasive, effective alternative In patients with CBD stones who have
previously undergone cholecystectomy, ES is the method of choice
Open surgery vs Endoscopic sphincterotomy
In patients with intact gallbladders, ES or open choledochotomy? Design: 237 patients with CBD stone and intact gallbladders, 66% managed with ES and
rest with open choledochotomy Results: No significant difference in morbidity and mortality rates
Lower incidence of retained stones after open choledochotomy Conclusion: open surgery superior to ES in those with intact gallbladders
Miller et al. Ann Surg 1988; 207: 135-41
Is ES followed by open CCY superior to open CCY+ CBDE? Results: Initial stone clearance higher with open surgery (88% vs 65%, p< 0.05) Conclusion: routine preoperative ES not indicated
Stain et al. Ann Surg 1991; 213: 627-34
Cochraine database of systematic reviews Design: 8 trials randomized 760 patients comparing ERCP with open surgical clearance Results: Open surgery more successful in CBD stone clearance, associated with lower
mortality Conclusion: open bile duct surgery superior to ES
Cochrane database of systematic reviews 2007
In patients with severe cholangitis, open or ES? Study design: Randomized, prospsective trial of 82 patients with choledocholithiasis and severe
toxic cholangitis managed endoscopically or with open choledochotomy Results: In group managed initially with endoscopic drainage, need for ventilatory support
(29% vs 63%) and mortality (33% vs 66%) significantly less Conclusion: toxic cholangitis should managed with endoscopic sphincterotomy
Lai et al. J Engl J Med 1992; 326: 1582-6
Laparoscopic CBD Exploration
In 1989, laparoscopic removal of gallbladder replaced open surgery In the past decade, laparoscopic CBD exploration (LCBDE) developed
Techniques IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones Choledochotomy
If cystic duct < CBD stone, If CBD > 6mm If stone located proximal to cystic duct-common bile duct junction If stone impacted in bile duct or papilla
Transcystic approach If CBD < 6mm in diameter Cystic duct dissected close to junction with CBD, transverse incision made Guidewire into CBd through cholangiogram catheter under fluoroscopy Osotonic NaCl irrigate CBD to flush small stones through sphincter of Oddi Unsuccessful in 10-20% of patients Contraindications: pancreatitis, sphincter anomalies,
Results High rate of lap CBD clearance: 73-100%
Similar success rates between transcystic and choledochotomy Conversion to open 5.2-19.6%
Causes : multiple/impacted stones, bleeding, unclear anatomy,equipment failure Length of hospital stay shorter in LCBDE than ES Mortality and Morbidity
No difference between LCBDE and ESCochrane database of systematic reviews 2007
Post-op Diagnosis and Management
T-tube cholangiography T-tube placed following CBDE to diagnosis and
manage retained stones Retained CBD stones in 2-10% of patients after
CBD exploration If not obstruction, tube is clamped and left for 6
weeks. Cholangiogram repeat after 6 wks
ERCP Treatment of retained stones undetected or left
behind
In summary Non-surgical care first line
Goal: extract stone, but if not possible, drain bile to improve condition until definitive surgical intervention
ERCP: both diagnostic and therapeutic Stones> 1cm - Sphincterotomy needed before extraction Stones > 2cm: require lithotripsy or chemical dissolution
PTC Surgical Care if endoscopy and IR drainage fail
Issues Exploration of CBD Fate of gallbladder
CBD exploration: laparoscopy first line Transcystic: Choledochotomy
CBD exploration: open If laparoscopy has failed or contraindicated T-tube cholangiogram 10-14 days posto Open CBD is safe option, but limited to setting of concomitant open surgery
…our case Open procedure
Due to previous failure of ERCP due to duodenum diverticulum Incision joining epigastric port with subcostal inciion Dis
Cholecystectomy Gallbladder was dissected free from liver bed Cystic artery/duct identified, ligated.
CBD exploration 2 suture splaced in direction of common duct through anterior wall in the
same longitudinal direction Choledochotomy- extended in both proximal and distal directions of
CBD 4 CBD stones evacuated Catheter advanced within CBD to perform sphincterotomy T-tube placed within common bile duct.