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

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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

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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.