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Surgery cholangitis[1]
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Surgery cholangitis[1]



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  • We know that she has elevated LFTs.


  • 1. Cholangitis & Management ofCholedocholithiasis 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/intrahepatic/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
  • 5. 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
  • 6. 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%).
  • 7. Clinical Manifestations RUQ pain (65%) Charcot’s Fever (90%) Triad: Found in Reynold’s  May be absent in elderly patients 50-70% Pentad: Jaundice (60%) of patients Hypotension (30%) Altered mental status (10%) Additional History Pruitus, acholic stools PMH for gallstones, CBD stones, Recent ERCP, cholangiogram Additional Physical Tachycardia Mild hepatomegaly
  • 8. 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
  • 9. 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 casesCT 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 Soto et al. J. Roenterology. 2000
  • 10. Diagnostic: MRCP and ERCPMagnetic 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%
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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 ES Cochrane database of systematic reviews 2007
  • 20. 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
  • 21. 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
  • 22. …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.