Cholangitis & Management of Choledocholithiasis

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Cholangitis & Management of Choledocholithiasis. Ruby 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: - PowerPoint PPT Presentation

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  • Cholangitis &Management of CholedocholithiasisRuby Wang MS 3Surg 300A8/20/07

  • ContentCase

    CholangitisClinical manifestationsDiagnosisTreatment

    Diagnosis and management of choledocholithiasisPre-operativeIntra-operativePost-operative

  • CaseHPI: 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 otherwisePE: VS: T 36.2, P98 , RR 18, BP 124/64Abdominal exam significant for RUQ TTPLabsAST 553, ALT 418. Alk Phos 466. Bilirubin 2.7WBC 30.3ImagingAbdominal US: multiple gallstones, no pericholecystic fluid, no extrahepatic/intrahepatic/CBD dilatation

  • IntroductionCholangitis is bacterial infection superimposed on biliary obstruction

    First described by Jean-Martin Charcot in 1850s as a serious and life-threatening illness

    CausesCholedocholithiasisObstructive tumorsPancreatic cancerCholangiocarcinomaAmpullary cancerPorta hepatisOthersStrictures/stenosisERCPSclerosing cholangitisAIDSAscaris lumbricoides

  • EpidemiologyNationalityU.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 AmericansIntestinal parasites common in Asia

    SexGallstones more common in womenM: F ratio equal in cholangitisAgeMedian age between 50-60Elderly patients more likely to progress from asymptomatic gallstones to cholangitis without colic

  • PathogenesisNormally, 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 bactibiliaE 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%).

  • Clinical ManifestationsRUQ pain (65%)Fever (90%)May be absent in elderly patientsJaundice (60%)Hypotension (30%)Altered mental status (10%)

    Charcots Triad:Found in 50-70% of patientsReynolds Pentad:

    Additional HistoryPruitus, acholic stoolsPMH for gallstones, CBD stones, Recent ERCP, cholangiogramAdditional Physical TachycardiaMild hepatomegaly

  • Diagnosis: lab valuesCBC79% of patients have WBC > 10,000, with mean of 13,600Septic patients may be neutropenicMetabolic panelLow calcium if pancreatitis88-100% have hyperbilirubinemia 78% have increased alkaline phosphataseAST and ALT are mildly elevatedAminotransferase can reach 1000U/L- microabscess formation in the liverGGT most sensitive marker of choledocholithiasisAmylase/LipaseInvolvement of lower CBD may cause 3-4x elevated amylaseBlood cultures20-30% of blood cultures are positive

  • Diagnosis: first-line imagingUltrasonographyAdvantage: Sensitive for intrahepatic/extrahepatic/CBD dilatation CBD diameter > 6 mm on US associated with high prevalence of choledocholithaisisOf cholangitis patients, dilated CBD found in 64%,Rapid at bedsideCan image aorta, pancreas, liverIdentify complications: perforation, empyema, abscessDisadvantageNot useful for choledocholithiasis: Of cholangitis patients, CBD stones observed in 13% 10-20% falsely negative - normal U/S does not r/o cholangitisacute obstruction when there is no time to dilateSmall stones in bile duct in 10-20% of cases CTAdvantagesCT cholangiograhy enhances CBD stones and increases detection of biliary pathologySensitivity for CBD stones is 95%Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscessCan visualize other pathologies- cholangitis: diverticuliits, pyelonephritis, mesenteric ischemia, ruptured appendixDisadvantagesSensitivity to contrastPoor imaging of gallstonesMed.virgina.eduSoto et al. J. Roenterology. 2000

  • Diagnostic: MRCP and ERCPMagnetic resonance cholangiopancreatography (MRCP)AdvantageDetects choledocholithiasis, neoplasms, strictures, biliary dilationsSensitivity of 81-100%, specificity of 92-100% of choledocholithiasisMinimally invasive- avoid invasive procedure in 50% of patientsDisadvantage: cannot sample bile, test cytology, remove stoneContraindications: pacemaker, implants, prosthetic valves IndicationsIf cholangitis not severe, and risk of ERCP high, MRCP usefulIf 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 dysfunctionAdvantageTherapeutic option when CBD stone identifiedStone retrieval and sphincterotomyDisadvantageComplications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleedingDiagnostic ERCP complication rate 1.38% , mortality rate 0.21%

  • Medical TreatmentResucitate, Monitor, Stabilize if patient unstableConsider cholangitis in all patients with sepsis

    AntibioticsEmpiric broad-spectrum Abx after blood cultures drawnAmpicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)Carbapenems: gram negative, enterococcus, anaerobesLevofloxacin (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 treatmentEndoscopic biliary drainageEndoscopic sphincterotomy with stone extraction and stent insertionCBD stones removed in 90-95% of casesTherapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression

    SurgeryEmergency surgery replaced by non-operative biliary drainageOnce acute cholangitis controlled, surgical exploration of CBD for difficult stone removalElective surgery: low M & M compared with emergency surveyIf emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

  • Our caseCondition: No acute distress, reasonably soft abdomenERCP attemptedDuct unable to cannulate due to presence of duodenum diverticulum at site of ampulla of Vater

    Laparoscopic cholecystectomy plannedDissection of triangle of CalotCystic duct and artery visualized and dissectedCystic duct ductotomyInsertion of cholangiogram catheter advanced and contrast bolused into cystic duct for IOC

    Intraoperative cholangiogramSeveral common duct filling defects consistent with stonesDecision to proceed with CBD exploration

  • CholedocholithiasisCholedocholithiasis develops in 10-20% of patients with gallbladder disease

    At least 3-10% of patients undergoing cholecystectomy will have CBD stonesPre-opIntra-opPost-op

  • Pre-op diagnosis & managementDiagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCPHigh risk (>50%) of choledocholithiasis: clinical jaundice, cholangitis,CBD dilation or choledocholithiasis on ultrasoundTbili > 3 mg/dL correlates to 50-70% of CBD stoneModerate risk (10-50%): h/o pancreatitis, jaundice correlates to CBD stone in 15%elevated preop bili and AP, multiple small gallstones on U/SLow risk (
  • Intra-op diagnosis and managementDiagnosis: 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 stonesPotentially identify bile duct abnormalities, including iatrogenic injuriesSensitivity 98%, specificity 94%Morbidity and mortality low

    TreatmentOpen CBD explorationMost surgeons prefer less invasive techniquesLaparoscopic CBD explorationvia choledochotomy: CBD dilatation > 6mmvia cystic duct (66-82.5%)CBD clearance rate 97%Morbidity rate 9.5%Stones impacted at Sphincter of Oddi most difficult to extractIntraoperative ERCP

  • Early years: Open CBD exploration & Introduction of endoscopic sphincterotomy1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon Kocherization of duodenum and short longitudinal choledochotomyStones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainageFor many years, this was the standard treatment for cholecystocholedocholithiasis

    1970s, endoscopic sphincterotomy (ES)Gained wide acceptance as good, less invasive, effective alternativeIn patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choice

  • Open surgery vs Endoscopic sphincterotomyIn 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 choledochotomyResults: No significant difference in morbidity and mortality ratesLower incidence of retained stones after open choledochotomyConclusion: open surgery superior to ES in those with intact gallbladdersMiller 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