Cholangitis

1
Cholangitis Management of Choledocholithiasis

• Ruby Wang MS 3
• Surg 300A
• 8/20/07

2
Content

• Case
• Cholangitis
• Clinical manifestations
• Diagnosis
• Treatment
• Diagnosis and management of choledocholithiasis
• Pre-operative
• Intra-operative
• Post-operative

3
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/intrahepati
  c/CBD dilatation

4
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

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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

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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
7
Clinical Manifestations

• RUQ pain (65)
• Fever (90)
• May be absent in elderly patients
• Jaundice (60)
• Hypotension (30)
• Altered mental status (10)

Charcots Triad Found in 50-70 of patients
Reynolds Pentad
Additional History Pruitus, acholic stools PMH
for gallstones, CBD stones, Recent ERCP,
cholangiogram Additional Physical
Tachycardia Mild hepatomegaly
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Diagnosis lab values

• CBC
• 79 of patients have WBC gt 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

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Diagnosis first-line imaging

• Ultrasonography
• Advantage
• Sensitive for intrahepatic/extrahepatic/CBD
  dilatation
• CBD diameter gt 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

Med.virgina.edu
Soto et al. J. Roenterology. 2000
10
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 Charcots 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

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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

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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
  MM compared with cholecystectomy with CBD
  exploration

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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

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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

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Pre-op diagnosis management

• Diagnosis Clinical history and exam, LFTs,
  Abdominal U/S, CT, MRCP
• High risk (gt50) of choledocholithiasis
• clinical jaundice, cholangitis,
• CBD dilation or choledocholithiasis on ultrasound
• Tbili gt 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 (lt5)
• large gallstones on U/S
• no h/o jaundice or pancreatitis,
• normal LFTs
• Treatment
• ERCP
• Surgery

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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 gt 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

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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

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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, plt 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?
  

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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 lt CBD stone, If CBD gt 6mm
• If stone located proximal to cystic duct-common
  bile duct junction
• If stone impacted in bile duct or papilla
• Transcystic approach
• If CBD lt 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

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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

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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
• Stonesgt 1cm - Sphincterotomy needed before
  extraction
• Stones gt 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

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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.