Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis

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Choledocholithiasis, Ascending Cholangitis, and Gallstone Pancreatitis Siriboon Attasaranya, MD, Evan L. Fogel, MD, Glen A. Lehman, MD * Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA Gallstone disease is one of the most common and most costly digestive diseases that require hospitalization in the United States with an estimated annual direct cost of $5.8 billion [1]. Gallstone disease is newly diagnosed in more than 1 million people annually in the United States, and cholecystec- tomy is performed in 700,000 cases [2]. The prevalence of gallstones has ethnic variability, with prevalence rates of approximately 10% to 15% in the United States and Europe [3]. The clinical spectrum of cholelithiasis ranges from an asymptomatic state to fatal complications. Patients who have asymptomatic gallstones carry an annual risk of approximately 1% for biliary colic [4,5], of 0.3% for acute cholecystitis [4–6], of 0.2% for symptomatic choledocholithiasis [5,6], and of 0.04% to 1.5% for gallstone pancreatitis (GSP) [7,8]. These small per- centages, however, represent a large number of patients, given the overall prevalence of gallstones. Gallstone pathophysiology Gallstones are classified into cholesterol stones and pigment stones. Stones composed mostly of cholesterol account for 80% to 90% of patients undergoing cholecystectomy in Western countries [9]. In normal bile, choles- terol is soluble in the form of mixed micelles with an optimal concentration of bile salts and phospholipids. With disproportionate concentrations, bile becomes supersaturated, and the excess cholesterol precipitates as monohy- drate crystals. These crystals embed in the gallbladder mucin gel with * Corresponding author. E-mail address: [email protected] (G.A. Lehman). 0025-7125/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2008.03.001 medical.theclinics.com Med Clin N Am 92 (2008) 925–960

Transcript of Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis

Page 1: Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis

Choledocholithiasis, AscendingCholangitis, and Gallstone Pancreatitis

Siriboon Attasaranya, MD, Evan L. Fogel, MD,Glen A. Lehman, MD*

Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University

Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA

Gallstone disease is one of the most common and most costly digestivediseases that require hospitalization in the United States with an estimatedannual direct cost of $5.8 billion [1]. Gallstone disease is newly diagnosed inmore than 1 million people annually in the United States, and cholecystec-tomy is performed in 700,000 cases [2]. The prevalence of gallstones hasethnic variability, with prevalence rates of approximately 10% to 15% inthe United States and Europe [3].

The clinical spectrum of cholelithiasis ranges from an asymptomatic stateto fatal complications. Patients who have asymptomatic gallstones carry anannual risk of approximately 1% for biliary colic [4,5], of 0.3% for acutecholecystitis [4–6], of 0.2% for symptomatic choledocholithiasis [5,6], andof 0.04% to 1.5% for gallstone pancreatitis (GSP) [7,8]. These small per-centages, however, represent a large number of patients, given the overallprevalence of gallstones.

Med Clin N Am 92 (2008) 925–960

Gallstone pathophysiology

Gallstones are classified into cholesterol stones and pigment stones.Stones composed mostly of cholesterol account for 80% to 90% of patientsundergoing cholecystectomy in Western countries [9]. In normal bile, choles-terol is soluble in the form of mixed micelles with an optimal concentrationof bile salts and phospholipids. With disproportionate concentrations, bilebecomes supersaturated, and the excess cholesterol precipitates as monohy-drate crystals. These crystals embed in the gallbladder mucin gel with

* Corresponding author.

E-mail address: [email protected] (G.A. Lehman).

0025-7125/08/$ - see front matter � 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.mcna.2008.03.001 medical.theclinics.com

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bilirubinate to form biliary sludge, which can aggregate eventually intoa gallbladder stone [10].

Black pigment stones make up a small proportion of gallstones. Thesestones consist of polymerized calcium bilirubinate, precipitated as a resultof exceeding the solubility of calcium and unconjugated bilirubin.Conditions that create excessive unconjugated bilirubin, such as chronichemolysis in hemoglobinopathies, cirrhosis [11], ineffective erythropoiesis,and ileal diseases [12], predispose a patient to the formation of blackpigment stones. Brown pigment stones are formed primarily in the bileduct. They result from bacterial infection that releases b-glucuronidaseto hydrolyze glucuronic acid from bilirubin. This process leads todecreased solubility of deconjugated bilirubin and formation of brownpigment stones.

Risk factors for gallstones

Risk factors for gallstone formation may be modifiable or nonmodifiable(Box 1). Environmental factors and genetic predisposition probably playinteractive roles in gallstone formation. An inflammatory immune responsemay contribute to a patient’s susceptibility to cholesterol stone formation[13].

Box 1. Risk factors of gallstones

Nonmodifiable factorsIncreasing ageFemale genderEthnicityGenetics, family history

Modifiable factorsPregnancy and parityObesityLow-fiber, high-calorie dietProlonged fastingDrugs: clofibrate, ceftriaxoneOral contraceptivesLow-level physical activitiesRapid weight loss (> 1.5 kg/wk)Hypertriglyceridemia/low high-density lipoproteinMetabolic syndromeGallbladder stasisSpecific diseases (ie, cirrhosis, Crohn’s disease with severe ileal

involvement/resection)

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Role of genetics

Geographic variations and ethnic differences in prevalence suggesta genetic role in the formation of gallstones. The prevalence of gallstonesis increased in families and in identical twins of patients who have gallstones[3]. The genes responsible for biliary lipid transport across the hepatic canal-iculi [10,14] and for lipid metabolism [3] have been identified.

Role of gallbladder stasis

Impaired gallbladder contractility has been noted in some patients whohave gallbladder stones. Although gallbladder dysfunction can result fromgallstone disease or from excessive cholesterol infiltration into gallbladdersmooth muscle [10], gallbladder stasis, by itself, can contribute to gall-bladder stone formation. Gallbladder stasis frequently is evident inpatients who have risk factors for cholelithiasis, including obesity, preg-nancy, rapid weight loss, and prolonged fasting [15]. Furthermore, gall-bladder dysmotility seems to be an independent risk factor for recurrentgallstones in patients treated with extracorporeal shockwave lithotripsy(ESWL) [16].

Prevention of gallstones

Moderate physical activity and dietary management (high fiber intakeand avoidance of saturated fatty acids) can lower the risk of cholelithiasis[17]. Daily administration of cholecystokinin in patients receiving pro-longed total parenteral nutrition was shown to prevent the formationof gallbladder sludge in one small series [18]. Oral ursodeoxycholic acid(UDCA) has been demonstrated to help prevent cholelithiasis duringrapid weight loss and in patients requiring long-term somatostatin ther-apy [17]. For secondary prevention, there currently are insufficient datato support the use of medical therapy, such as UDCA, for preventionof biliary colic or for prevention of complications in patients who havegallstones who are awaiting cholecystectomy or who are unfit for surgery[17,19].

Choledocholithiasis: special consideration

Primary versus secondary bile duct stones

In the Western world, most stones in the common bile duct arise from thepassing of gallbladder stones into the common bile duct. Stones in thecommon duct occur in 10% to 15% of people who have gallbladder stones.Concomitant gallbladder stones and bile duct stones occur more frequentlyin elderly, Asian patients and in patients who have chronic bile duct

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inflammation (such as sclerosing cholangitis, parasitic infestation) and,probably, hypothyroidism [20].

Primary bile duct stones are formed in the intrahepatic or extrahepaticbile ducts. They are more prevalent in Asian populations. These stones usu-ally are brown pigment stones. Bacterial colonization of bile and bile stasisplay important roles in the pathogenesis of these stones [21,22].

Clinical spectrum

Coexisting bile duct stones and gallbladder stones

Bile duct stones can be discovered incidentally during the evaluation ofgallbladder stones, with an estimated prevalence of 5% to 12% [23,24]. Itis difficult to determine whether the existing bile duct stones are asymptom-atic in patients who present with biliary pain alone, because the pain canoriginate from either the gallbladder stones or bile duct stones. Approxi-mately one third of patients have spontaneous bile duct stone passage basedon stone disappearance 6 weeks after diagnosis, as determined in one studyby cholangiograms using an in situ cholangiogram catheter [25]. Given thepotential serious complications of bile duct stones, specific therapy generallyis indicated regardless of symptoms.

Symptomatic bile duct stones

Patients who have symptomatic bile duct stones are at high risk of expe-riencing further symptoms or complications if left untreated. More than onehalf of patients who had retained bile duct stones experienced recurrentsymptoms during a follow-up period of 6 months to 13 years [26], and25% of patients developed serious complications [27].

Common clinical symptoms and signs include pain, fever, and jaundice.Biliary pain confined to the epigastrium or right upper quadrant of theabdomen is the most common presentation. Pain is variably mild tosevere at onset. Severe episodes commonly require emergency medicalvisits and must be differentiated from cardiac or other potentially life-threatening events. Infrequently, patients present with painless jaundiceand weight loss that mimics pancreatobiliary malignancy. Acute ascendingcholangitis and acute pancreatitis are two serious, life-threateningcomplications.

Diagnosis of bile duct stones

Although advanced technologies have become more widely available,a clinically oriented approach remains paramount. Atypical as well as typ-ical clinical symptoms should be recognized. Newer techniques of biliaryimaging have simplified the diagnosis of bile duct stones. Noninvasive

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methods have the lowest risk, whereas invasive techniques have the great-est accuracy.

Blood tests

Patients who have cholangitis or pancreatitis associated with abnormal

serum liver function tests are at increased risk of having bile duct stones.Elevations of serum alkaline phosphatase and gamma-glutamyl transpepti-dase levels were detected in more than 90% of symptomatic patients [28].The intensity of pain, degree of jaundice, and serum levels of these testscan fluctuate over time. The serum bilirubin level typically is less than15 mg/dL, because most bile duct stones cause intermittent and incompletebiliary obstruction. Rarely, the serum transaminase levels can be elevatedprofoundly (up to 2000 IU/L), mimicking acute viral hepatitis. With biliarystones, however, these levels tend to decline rapidly over several days [29]rather than slowly over several weeks, as occurs with viral syndromes. Inthis clinical setting sequential follow-up of the pattern of liver function testsmay be helpful diagnostically.

Imaging studies for diagnosis of bile duct stones

Transabdominal ultrasound (TUS) is the most commonly used initial

diagnostic tool for suspected biliary stones. Gallbladder stones, if present,generally are well visualized if the gallbladder is adequately distended andnot obscured by luminal gas or obesity. TUS has low sensitivity (25%–60%) for the detection of bile duct stones , but it has a very high specific-ity [30,31]. Indirect evidence, such as the presence of gallstones or biliaryductal dilation, in the appropriate clinical setting is predictive of bile ductstones, but the obstructed bile duct may not be dilated with acute obstruc-tion. CT scanning has a similarly low sensitivity in the detection of bileduct stones and is used primarily to document biliary dilation, to excludeother causes of biliary obstruction (eg, a mass lesion), and to detect localcomplications such as liver abscess. Magnetic resonance cholangiopancrea-tography (MRCP) and endoscopic ultrasound (EUS) are less invasive thanendoscopic retrograde cholangiography (ERC) but can detect bile ductstones with comparable accuracy. Recently, use of multidetector CT, inconjunction with oral or intravenous contrast and with reconstruction ofaxial and three-dimensional images, has been reported to have a sensitivityof 85% to 97% and specificity of 88% to 96% in the diagnosis of bile ductstones [43–46]. Although this accuracy is comparable to that of MRCP,this method is limited by (1) relatively frequent allergic reactions to thecontrast agents, as high as 15% in one series using intravenous iotroxate[45]; (2) suboptimal ductal contrast opacification in the presence of signif-icant jaundice (bilirubin more than two or three times the upper limits ofnormal) or in a patient who has undergone cholecystectomy [43,47]; and(3) limited visualization of intrahepatic duct branches, particularlywhen using oral contrast agents [45,48]. Table 1 summarizes the clinical

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Table 1

Imaging studies for diagnosis of common bile duct stones

Characteristic TUS CT MRC EUS ERC

Sensitivity (%) 25–63 [30,31] 71–75 [30,31] 85 [32] 93–98 [32–34] 90–97 [35,36]

Specificity (%) 95–100 [30,31] 97 [30,31] 93 [32] 97–100 [32–34] 95–100 [35,36]

Advantages Inexpensive Safe

Widely available

Portable

Detection of concomitant

intrahepatic duct stones,

liver parenchymal lesions,

and pancreatic lesions

High accuracy for duct

stone detection

Noninvasive intrahepatic

and extrahepatic duct

evaluation

High accuracy for duct

stone detection

Less invasive than ERC

Detects small stones in

a nondilated duct [30]

High accuracy

Therapeutic potential

Disadvantages Low sensitivity

Operator dependent

Radiation exposure

Contrast allergy

Renal impairment

Expensive

Time consuming

Limited value in stones

! 6 mm [37]

Impacted stone at the

ampulla [38], dilated bile

duct O 10 mm [39]

Claustrophobia

Ferromagnetic implant

Artifact interferencea

[40–42]

Operator dependent

High cost of equipment

Insensitive for proximal

common hepatic duct /

intrahepatic duct stones

Higher risk than EUS

False positives (air bubbles)

False negatives with small

stones in dilated duct

Unsuccessful cannulation

Abbreviations: ERC, endoscopic retrograde cholangiography; EUS, endoscopic ultrasound; MRC, magnetic resonance cholangiography; TUS, transab-

dominal ultrasound.a Including pneumobilia, flow artifact, duodenal diverticula.

930

ATTASARANYAet

al

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applications and limitations of imaging studies in the diagnosis of bile ductstones.

ERC is considered the reference standard for the diagnosis of bile ductstones and provides an opportunity for therapy. Because of potential signif-icant procedure-related risks and the availability of the other, less invasive,accurate imaging modalities, ERC now is reserved for patients who haveconfirmed bile duct stones or who are at high risk for bile duct stones(Table 2) who probably will require therapeutic intervention [49].

Recurrent bile duct stones

Bile duct stones recur in about 4% to 24% of patients during a follow-upperiod of 15 years [42]. Stones even can recur in patients after gallbladderremoval. It remains uncertain, however, what proportion of these recurrentstones are, in fact, overlooked retained/residual stones from the prior ther-apy. Recurrence is thought to be causedmainly by bile stasis and bacterobilia.Main duct dilation (R 13 mm) and the presence of a periampullary divertic-ulum are common risk factors for recurrent stones [42,50], perhaps resultingfrom increased biliary stasis. Identification and treatment of correctable riskfactors, such as biliary strictures, papillary stenosis, and gallstones in patientswho have gallbladder in situ, is essential to prevent recurrence.

Detection of bile duct stones after endoscopic therapy

After biliary endoscopic sphincterotomy (BES), the biliary systemfrequently is filled with air. The bile duct may be dilated persistently despiteremoval of all bile duct stones. These two factors may decrease the accuracyof imaging tests in detecting residual/recurrent stones after endoscopic ther-apy. MRCP seems to have limited value in detecting stones in an air-filledduct [51]. In this setting, intraductal EUS, in conjunction with ERC, hasbeen reported to detect stones in the dilated duct with a greater accuracythan achieved with ERC alone [52].

Table 2

Risk classification of probability of bile duct stones based on clinical presentation and transab-

dominal ultrasound evaluation

Parameters

High Risk

(O 50%)

Moderate Risk

(10%–50%) Low Risk (! 5%)

Jaundice Current History of jaundice No history of jaundice

Liver function tests Persistently elevated Declining Normal

Cholangitis Current History of fever No history of fever

Pancreatitis Current History of pancreatitis No history of pancreatitis

Common bile

duct diameter

Dilated bile duct

(R 10 mm)

Borderline dilated Normal

Ductal stones seen Yes Questionable

(with small

gallbladder stones)

None (with large

gallbladder stones)

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Therapy of bile duct stones

Biliary endoscopic sphincterotomy

Since its introduction in 1974, BES has supplanted surgery as the stan-dard therapy for bile duct stones. About 85% to 90% of bile duct stonescan be removed by balloon/basket extraction following BES. In a large,multicenter trial, the overall complication rate of BES was 9.8% in 2347 pa-tients, including pancreatitis in 5.4%, bleeding in 2%, procedure-relatedcholangitis in 1%, cholecystitis in 0.5%, and perforation in 0.3% [53]. Inthe subgroup of 1600 patients who had common duct stones, the overallcomplication rate was 8%.

Treatment of difficult bile duct stones

Approximately 10% to15% of patients have bile duct stones that cannotbe removed using standard BES and balloon/basket extraction techniques.These stones generally are larger than 1.5 cm, are impacted, or are locatedproximal to strictures [54]. Alternative therapies have been used to managethese difficult bile stones.

Fragmentation of stones

Mechanical lithotripsy. Mechanical lithotripsy is the simplest and mostwidely used technique for fragmenting stones. The lithotripter unit isdesigned as either an integrated device or a salvage device that consists ofa metal sheath with a handle applicable to lithotripsy-compatible wire bas-kets. In two studies, mechanical lithotripsy successfully removed 85% to90% of ‘‘difficult’’ bile duct stones [55,56]. Mechanical lithotripsy usuallyis successful only in stones smaller than 3 cm [55]. The most common reasonfor unsuccessful mechanical lithotripsy is inability to capture the stones (eg,inadequate space to open the basket).

Electrohydraulic lithotripsy. An electrohydraulic lithotripsy system consistsof a bipolar probe and a charge generator. Initiation of a spark causes ex-pansion of the surrounding fluid that generates shock waves to fragmentstones. Electrohydraulic lithotripsy can be operated under either fluoro-scopic or direct cholangioscopic guidance. Direct visualization is preferredto permit deployment of the probe at the surface of the stone to ensurethe highest efficacy and to avoid ductal injury. This technique seems to behelpful in patients who have concomitant intrahepatic duct stones or biliarystrictures [57]. A disadvantage of using cholangioscopy for electrohydrauliclithotripsy is the need for two operators and the use of a fragile intraductalminiscope. Recently, single-operator cholangioscopy has been used to directelectrohydraulic lithotripsy therapy for bile duct stones; preliminary resultshave been encouraging [58].

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Extracorporeal shockwave lithotripsy. ESWL generates a shockwave origi-nating outside the body using piezoelectric, electrohydraulic, or electromag-netic systems. A liquid or tissue medium is required to prevent energyattenuation. Because ESWL is painful, general anesthesia or, less frequently,conscious sedation is required. Because most bile duct stones are not radi-opaque and are not visualized by fluoroscopy before contrast injection atendoscopic retrograde cholangiopancreatography (ERCP), a nasobiliarytube may be required before ESWL. Complete stone clearance rates of83% to 90% have been reported [59,60]. Most cases require several endo-scopic procedures to remove the fragmented stones.

Laser lithotripsy. In laser lithotripsy, laser light at a particular wavelength isfocused on the surface of a stone to achieve stone fragmentation. An oscil-lating plasma, consisting of a gaseous collection of ions and free electrons, iscreated to induce wave-mediated fragmentation of stones. Laser lithotripsyis performed under direct visualization using the cholangioscope or underfluoroscopic guidance. A recent-generation device can differentiate betweenthe light reflection patterns of the bile duct wall and those of stones. Thelaser beam is stopped immediately when bile ductal tissue is contacted toprevent bile duct injury. Experience with this modality is limited, however.The success rates of bile duct stone clearance with laser lithotripsy have beenreported at 64% to 97% [27].

Supplemental large-diameter biliary orifice balloon dilation

Endoscopic biliary orifice dilation (EBD) using a 6- to 8-mm diameter

balloon to remove bile duct stones has a reported success rate comparableto that of BES. This success rate, however, seems to require more ERCPsessions, more frequent use of mechanical lithotripsy, and, occasionally, res-cue BES. Most importantly, two meta-analyses have shown that the rate ofpancreatitis is significantly higher with EBD than with BES [61,62].

Use of a large-diameter (12–20 mm) dilation balloon as an adjunctivetool to enlarge an inadequate BES orifice can aid in the removal of largeor difficult bile duct stones. In a recent multicenter study of 103 patients,this technique had a success rate of 92% and a complication rate of7.6%, with a remarkably low rate of pancreatitis of 2.2% [63]. This lowrate of pancreatitis is attributed to the separate pancreatic and biliary ori-fices following BES, so that the pancreatic orifice is avoided during biliaryballoon dilation. Although this combined technique seems to be attractive,additional clinical experience is necessary.

Surgery

Laparoscopic bile duct exploration. Patients who have concomitant gallblad-der and bile duct stones are treated ideally with a single procedure: laparo-scopic cholecystectomy and laparoscopic bile duct exploration. In experthands, a single-stage laparoscopic procedure can achieve a stone clearance
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rate comparable to that of ERCP. Either a transcystic approach (for stones! 8–10 mm) or direct choledochostomy with choledoschoscopy (for largeror multiple stones) can be performed. This procedure is technically demand-ing, however, and only a minority of surgeons perform laparoscopic bileduct exploration. The reported success rates range from 80% to 98%,with complication rates of 4% to 16%, including bile duct injury, infection,pancreatitis, and stricture [64].

Open common bile duct exploration. Open common bile duct explorationgenerally is performed only if endoscopic and laparoscopic approachesare unsuccessful. Additionally, choledochoenterostomy or sphincteroplastycan be performed. The former procedure is preferable for stones largerthan 2 cm. Sump syndrome, which occurs when debris or food particles en-ter a side-to-side choledochoduodenostomy and block the distal bile duct,occurs in 1% of such cases and is managed by endoscopic therapy.

Long-term biliary stenting

Whenever stones cannot be removed completely endoscopically, biliary

stents should be placed to ensure adequate biliary drainage and to preventrecurrent symptoms as well as biliary sepsis while awaiting further therapy.Alternatively, long-term biliary stenting is used in patients who have severecomorbid medical conditions that preclude surgery or who have had re-peated endoscopic interventions for definitive therapy of bile duct stones[65–68]. The main goal is to prevent the impaction of stones. Additionally,long-term stenting can promote stone fragmentation, leading to decreasedstone size, and, occasionally, spontaneous passage of stones [65,69]. Internaland external pigtail stents are preferred to straight stents because they mi-grate less frequently and maintain the patency of the biliary orifice better.Straight stents may be used selectively for stones associated with a biliarystricture. Long-term biliary stenting, however, is associated with significantmortality, ranging from 6% to 16%, mainly from cholangitis, and with mor-bidity of up to 40% during 3 years of follow-up [70,71]. Moreover, new bileduct stones can occur in patients who had inadvertent long-term stent place-ment following therapy for bile duct stones [72]. In summary, long-termstenting should be reserved as a definitive therapy for patients who are atextremely high risk for endoscopic or surgical procedures or who havea short life expectancy.

Acute ascending cholangitis

Acute cholangitis, or infection of the biliary tree, occurs as a consequenceof biliary tract obstruction. The clinical presentation ranges from a mild,self-limited process to a serious, life-threatening condition requiring emer-gent intervention. Bile duct stones are the most common cause of acute

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cholangitis in Western countries [73]. Malignant obstruction rarely presentswith cholangitis do novo but can cause cholangitis after manipulation ofstent occlusion from the biliary tree. Indeed, previous therapy probably isthe second most common cause of acute cholangitis. Acute cholangitis isoccurring increasingly, secondary to biliary stricture from biliary surgery,orthotopic liver transplantation, primary sclerosing cholangitis, or AIDS-related cholangiopathy. These conditions are beyond the scope of thisdiscussion.

Pathophysiology

Bacterobilia occurs commonly in patients who have bile duct stones,often in the absence of clinical cholangitis. Typically, the main entry routeof bacteria is ascending from the duodenum [73]; the portal venous and peri-portal lymphatic systems serve as the portal of entry in a minority of cases[74]. In the presence of bacterobilia, biliary obstruction plays a critical rolein the pathogenesis of cholangitis. Increasing intraductal pressure leads todisruption of hepatocellular tight junctions, with subsequent translocation(reflux) of bacteria and biliary toxins into the bloodstream. The occurrenceof bacteremia or endotoxemia is correlated directly with the intrabiliarypressure [75,76]. Biliary obstruction promotes bile stasis and bacterialgrowth and also may compromise host immune defense mechanisms [77].

Diagnosis and clinical manifestations

Charcot, in 1877, described a triad of fever, right upper abdominal pain,and jaundice; this triad occurs in 56% to 70% of patients who have cholan-gitis [78]. The more severe form, characterized by the additional clinicalfeatures of hypotension and alteration of consciousness (Reynold’s pentad),is uncommon and occurs in only 5% to 7% of cases [79,80]. Fever is themost common presenting symptom, found in 90% of patients. The painin patients who have cholangitis, unlike the pain secondary to bile ductstones in the absence of infection, is relatively mild and intermittent. Elderlyand immunocompromised patients can present with atypical symptoms andsigns. The presence of fever, leukocytosis, and abnormal liver function testsis highly suggestive.

Laboratory tests

Leukocytosis and an elevated C-reactive protein level and erythrocytesedimentation rate are found commonly but are nonspecific. Liver functiontests invariably are elevated, with a widely variable range. Pancreaticenzyme elevations suggest that bile duct stones caused the cholangitis,with or without GSP [81].

Bile cultures are positive in 80% to 100% of patients who have chola-ngitis, and blood cultures are positive in 21% to 71% [82,83]. Enteric

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gram-negative organisms including Escherichia coli, Klebsiella, and Entero-coccus are isolated from bile commonly; Staphylococcus and Streptococcusare isolated infrequently. Anaerobic bacteria, such as Clostridium and Bac-teroides, are isolated more commonly in polymicrobial infections in patientswho have had prior biliary-enteric surgery, are elderly [73], or have severedisease [84,85]. Patients who have had recent biliary surgery or who have in-dwelling stents are more likely to harbor Enterococcus or hospital-acquiredorganisms such as Pseudomonas species, methicillin-resistant Staphylococcusaureus, vancomycin-resistant Enterococcus, or fungi [86].

Imaging tests

The choices in imaging are the same as for the diagnosis of bile ductstones but must be done more urgently in patients who have acute cholan-gitis. An early CT scan is recommended to evaluate for biliary dilation andsimultaneous liver abscesses.

Management of cholangitis

Early diagnosis and prompt appropriate therapy are essential. Closemonitoring and reassessment of the treatment response are important toguide the therapy. Patients who have mild disease are managed initiallywith medical therapy, including antibiotics and supportive medical care.Patients who respond promptly to medical therapy should undergo biliarydecompression and/or definitive therapy for bile duct stones as early as prac-tical, preferably within 24 to 48 hours. Patients who have severe or progres-sive disease require urgent biliary drainage in addition to medical therapy[87]. Delay in securing biliary drainage in this subgroup may produce a fataloutcome. A treatment algorithm is suggested in Fig. 1.

Medical therapy

Initially, antibiotics as well as supportive therapy, including adequatehydration and correction of coagulopathy and metabolic derangements,must be provided. Medical therapy alone is effective in approximately80% of patients; prompt additional biliary drainage is required in the othersto control the clinical symptoms.

Antibiotic therapy

Antibiotics should be given early when acute cholangitis is suspected,even before it is definitively established, to control bacteremia and sepsis.The choice of empiric antibiotics is based on several considerations, includ-ing host factors (renal function, allergic reactions), severity of disease, localsusceptibility pattern, community versus hospital-acquired infection, andthe presence of prior biliary intervention or surgery. Broad-spectrumantibiotics with adequate biliary excretion such as ampicillin/sulbactam,

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Acute cholangitis

Assess clinical status, prompt antibiotics, hydration, correct metabolic derangement

Mild Severe /unstable

Intensive care

Close monitoring/reassess in 6-12 hours

Favorable response Refractory/Progressive

Elective ERCP withdefinitive therapyof bile duct stones

(within 24-48 hours)

Urgent ERCP with

biliary decompression

± definitive therapy

favorable response unfavorable response/

Elective ERCPwith definitive therapy(if not previously done)

technical failure

Percutaneous drainage

altered anatomy (e.g.gastric bypass surgery)

Fig. 1. Algorithm for management of patients who have acute cholangitis.

937CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

piperacillin/tazobactam, third- or fourth-generation cephalosporins, quino-lones, and carbapenems are preferred. Antibiotics with enterococcal and an-aerobic coverage may be added in patients who have advanced age, severedisease, a biliary stent in situ, or prior enterobiliary surgery. Biliary excre-tion of most antibiotics is compromised in the presence of biliary obstruc-tion, however [83]. Early biliary decompression is essential to restore goodbiliary penetration of the antibiotics and to drain purulent bile, particularlyin patients who have severe disease. Once the micro-organisms have beenidentified and their susceptibility has been determined, the antibiotics shouldbe adjusted to cover the identified micro-organism and to avoid the emer-gence of antibiotic-resistant micro-organisms.

The duration of antibiotic therapy is based on the clinical response and thepresence of bacteremia. For mild disease, antibiotics generally are continuedfor 5 to 7 days. For patients who have a positive blood culture, a 10- to 14-daycourse of antibiotics is recommended. After a clinical response, switchingfrom intravenous to oral administration usually is appropriate. The optimalduration of antibiotic therapy following biliary drainage has not been welldefined in prospective, randomized trials. One small retrospective studyreported that a 3-day duration of antibiotic therapy following biliary drain-age seemed to be effective in selected patients who respond promptly (withresolution of fever) to drainage procedures [88].

Biliary drainage

Biliary decompression is essential in patients who have cholangitis.Decompression can be performed by endoscopic, percutaneous, or surgicalapproaches or by multimodal therapy.

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Endoscopic biliary decompression

An endoscopic approach offers several benefits, including defining ductal

anatomy, identifying simultaneous pathology (such as biliary strictures orcholedochal cysts), collecting bile for microbiologic study, providing tissuesampling, and allowing definitive therapy in most cases. In severe cholangi-tis biliary decompression and bile duct clearance by ERCP has lowermorbidity and mortality rates than open surgery with bile duct exploration[89,90]; in one prospective, randomized trial, the morbidity of the endo-scopic procedure was one half that of open surgery (34% versus 66%),and the mortality with the endoscopic procedure was one third that of theopen approach (10% versus 32%) [90]. Similarly, morbidity and mortalityin elderly patients are lower with EBD than with percutaneous drainage[91]. Endoscopic biliary decompression therefore is the procedure of choice,and percutaneous or surgical drainage is reserved as an alternative whenendoscopic therapy is technically impossible or is unsuccessful.

Evaluation before endoscopic retrograde cholangiopancreatography. Thepatient’s condition is stabilized as much as possible before the procedure.Adequate hydration and prompt administration of systemic antibiotics areessential. Details of prior surgeries that alter ERCP access should be iden-tified. Appropriate periprocedural and intraprocedural monitoring isneeded. Critically ill patients may require emergency ERCP using a mobilefluoroscopic unit at the bedside in the ICU. EBD without fluoroscopy hasbeen performed successfully in the ICU [92].

Endoscopic techniques of biliary drainage in acute cholangitis. When ERCPis performed in the presence of active cholangitis and purulent bile, caremust be taken to avoid aggravating the existing high intraductal pressure.Contrast injection during biliary cannulation should be minimized. Oncedeep cannulation is successful, 20 to 40 mL of bile should be aspirated todecompress the bile duct and to provide a sample of bile for microbiologicanalysis. Then limited contrast can be injected to fill only the extrahepaticductal system to define the cause and location of obstruction, unless intra-hepatic bile duct pathology is suspected. Definitive therapy (BES withremoval of stones) is pursued in a stable patient who has confirmed bileduct stones. In an unstable patient, every effort should be made to shortenthe procedure time while providing adequate biliary drainage; definitivetherapy can be performed subsequently once the patient is stable. Prolong-ing the procedure to attempt definitive therapy in an unstable patient mayincrease the morbidity and mortality.

In patients who have severe cholangitis, EBD can be achieved with plasticbiliary stents or with nasobiliary catheter drainage (NBD) with or withoutBES. Concomitant BES facilitates the placement of a larger stent (10–11.5 F)or multiple stents for more effective drainage and with a minimal risk ofstent migration. A large multicenter trial, however, noted that the risk

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939CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

of postsphincterotomy bleeding is correlated significantly with the presenceof acute ascending cholangitis, even in the absence of coagulopathy [53].Furthermore, one study comparing decompression by NBD alone (n ¼ 73)versus NBD with BES (n ¼ 93) showed comparable success rates butsignificantly more complications in the BES group (12% versus 2%),mainly from bleeding or cholecystitis [93]. Overall, the decision whetherBES should be performed is tailored to the individual patient. If coagulop-athy is present, or if the patient is unstable, placement of a biliary drainagetube alone (preferably a 7-F biliary stent or NBD), without BES, generallyis recommended for short-term drainage and produces satisfactory results[93,94]. BES may be performed when placement of a large (R 10 F) ormultiple stents is required. By separating the biliary and pancreaticorifices, BES can avoid compression of the pancreatic orifice by the stents,which otherwise could result in post-ERCP pancreatitis. In patients whohave a concomitant biliary stricture that requires dilation, BES also mayfacilitate stent placement through the tight stricture. In patients whohave cholangitis in whom ERCP is performed but no bile duct stonesare identified, BES has been shown to improve outcomes compared withno therapeutic intervention, with a faster recovery and shorter hospitaliza-tion [95].

Two prospective studies demonstrated no difference in treatment out-comes between biliary stenting and NBD in patients who had acute cholan-gitis [96,97]. NBD provides the advantage of active decompression byintermittent or continuous negative pressure suction and the opportunityfor sequential bacteriologic bile cultures. It is, however, less used frequentlybecause of patient discomfort, the possibility of inadvertent dislodgment ofthe nasobiliary catheter, the risk of kinking with inadequate drainage, andthe potential for electrolyte disturbances secondary to the external diversionof bile. No randomized, controlled trials have compared outcomes betweenstraight or pigtail biliary stents or among different stent sizes (7 F versuslarger size) in patients who have acute cholangitis. Theoretically, largerstents should provide better drainage, particularly if thick, purulent bileand stone debris are present. Because BES is needed for placement of largerstents, the risk of BES-related bleeding needs to be weighed against the po-tential benefit. Because most patients who have acute cholangitis undergodefinitive therapy for bile duct stones several days or weeks following suc-cessful biliary decompression, the type or size of stent is likely to have noeffect on treatment outcomes. In patients who have debilitating comorbidconditions, in whom the definitive therapy for bile duct stones is anticipatedto be delayed (ie, for months) or may be unsuccessful, BES with long-termplacement of multiple stents may be a reasonable alternative.

Percutaneous transhepatic biliary drainage

In percutaneous transhepatic biliary drainage a biliary drainage catheter

is placed under ultrasound or fluoroscopic guidance into an intrahepatic

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940 ATTASARANYA et al

duct and/or common bile duct, with the tip downstream in the duodenum.In expert centers, the overall success rate of percutaneous drainage ap-proaches 95% to 98% in patients who have biliary ductal dilation and is70% to 80% in patients who do not have biliary dilation [98]. Potential se-rious complications include sepsis, intraperitoneal hemorrhage, peritonitis,and pancreatitis [98]. Percutaneous transhepatic biliary drainage generallyis reserved for patients in whom endoscopic biliary drainage is unsuccessfulor who have altered anatomy such as prior gastric bypass surgery.

Surgical drainage

Either open or laparoscopic common duct exploration may be per-

formed. In severely ill patients, the simplest procedure (eg, T-tube place-ment) should be performed to shorten the procedure time. The option ofdefinitive therapy can be determined later, when appropriate. Because ofthe operative risks, emergency surgical decompression rarely is performed;it is reserved for patients in whom both endoscopic and percutaneous ap-proaches have been unsuccessful or who have altered anatomy that pre-cludes such approaches.

Gallstone pancreatitis

Gallstones are the most common cause of acute pancreatitis in Westerncountries. The incidence of GSP is increased in women more than 60 yearsold [99]. The pathogenesis is believed to be related to increased pancreaticductal pressure, possibly with biliopancreatic reflux, that occurred whenthe bile duct stone passed or was impacted at the ampulla. Multiple smallgallstones (! 5 mm), a dilated cystic duct, and good postprandial gallblad-der emptying are putative factors for GSP [100–102]. Anatomic variationssuch as a long common channel [103] or a nonpatent accessory duct [104]may be contributing risk factors.

Most stones pass spontaneously into the duodenum. Discovery of fecalstones has been reported in about 90% of patients suspected of havingGSP, in comparison with 10% of controls [105]. The disease recurs, how-ever, in approximately one third to two thirds of patients as early as 3months after the initial episode if the underlying biliary stones are left un-treated [106]. Although GSP usually is mild and self-limited, some patientshave a severe, complicated course that entails substantial mortality. Man-agement of patients who have severe disease is complex and has been de-bated for nearly a century.

Clinical presentation

Patients typically present with a sudden onset of unrelenting upper ab-dominal pain, which radiates into the back in about 50% of cases. Nauseaand/or vomiting frequently occur. An elevated serum amylase and/or lipase

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941CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

level three times the upper limit of normal or higher in the typical clinicalsetting is diagnostic. When patients experience sudden severe abdominalpain, other serious conditions should be considered and need to be excluded(Box 2). Notably, other potentially life-threatening conditions, such as a per-forated viscus or bowel ischemia, can produce modest elevation of the serumamylase or lipase level.

Diagnosis

Recognition of GSP is crucial, because urgent endoscopic interventionmay prevent complications and mortality in selected cases, and specific ther-apy of bile duct stones is essential to prevent recurrence. As noted earlier,the diagnosis of acute pancreatitis is based on the characteristic pain andelevated serum amylase or lipase levels. Suspicion of GSP is increased inpatients who have acute pancreatitis associated with abnormal liver functiontests, documented gallbladder stones, or biliary dilation in the absence ofother causes [107,108]. A history of excessive alcohol use, known gallstonedisease, previous/current medication use, abdominal trauma/surgery, previ-ous episodes of pancreatitis, family history, and weight loss that suggestsa malignant process should be obtained. Liver function tests, triglyceridelevels, and the serum calcium level also should be obtained at presentation.In selected cases, additional blood tests to exclude autoimmune pancreatitis(anti-nuclear antibodies, IgG4) or genetically related pancreatitis (cysticfibrosis, hereditary pancreatitis) should be considered.

Liver function tests

Elevation of alanine aminotransferase more than three times the upper

limit of normal within 1 to 2 days after onset is the single best predictorof biliary pancreatitis, with a positive predictive value of 95% [109]. Any el-evation of liver function tests in patients who have acute pancreatitis should

Box 2. Differential diagnosis of acute pancreatitis

Gastrointestinal diseasesPerforation of hollow viscusMesenteric ischemia/infarctionIntestinal obstructionAcute cholecystitisAcute cholangitis

Non-gastrointestinal diseasesAcute inferior wall myocardial infarctionDissecting abdominal aortic aneurysmEctopic pregnancy

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942 ATTASARANYA et al

raise the possibility of GSP. A normal alanine aminotransferase level doesnot exclude GSP, however, because the sensitivity rate is only 48% [109].Moreover, liver function tests are entirely within the normal range in 10%of cases [110].

Serum amylase/lipase

The serum amylase level rises within 2 to 12 hours after the onset of

symptoms and normalizes within 3 to 5 days [111]. Serum lipase, derivedmainly from pancreatic acinar cells, peaks at 24 hours and may remain ele-vated for several days [112]. The serum amylase level tends to be higher withGSP than with alcoholic pancreatitis [113]. Clinical use of the height of theserum amylase/lipase is limited, however, because of overlapping values.Furthermore, the amount of the serum amylase/lipase elevation is notcorrelated with disease severity, and daily monitoring of these levels is oflimited value in predicting the progression or prognosis of acute pancreatitis[114].

Imaging studies

In patients suspected of having acute pancreatitis, initial imaging studies

are useful mainly in confirming the diagnosis and in excluding other abdom-inal emergencies. In patients who have a firm diagnosis, imaging studies maybe required to determine the potential cause (gallstones, bile duct dilation,underlying chronic pancreatitis, or neoplastic process) and to detect localcomplications (pancreatic necrosis, fluid collection) in patients who havesevere pancreatitis.

Abdominal plain roentgenograms

Abdominal plain roentgenograms contribute little to the diagnosis. The

‘‘sentinel loop’’ of distended small bowel is rare and does not affect manage-ment. The primary value of plain roentgenograms is to exclude otherabdominal emergencies such as intestinal perforation or obstruction. Pan-creatic calcifications, indicating underlying chronic pancreatitis, or opaquegallbladder stones are detected rarely.

Transabdominal ultrasound

TUS is the first line of investigation for GSP because of its low cost, its

availability, and its portability for bedside examination of the critically illpatient. The primary value of TUS for acute pancreatitis is to documentthe presence of gallbladder stones and/or bile duct dilation, suggestingGSP. Although TUS is highly accurate for the diagnosis of gallstones inthe absence of pancreatitis, it is only 60% to 80% sensitive in detectinggallstones during an attack of acute pancreatitis, presumably because ofoverlying bowel gas [114,115]. In particular, small gallstones (mean size,! 4 mm) may be missed by TUS [116]. EUS or an interval TUS mayhelp in this situation.

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943CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

CT scanning

A dynamic contrast-enhanced CT scan is the optimal tool for detecting

pancreatic parenchymal and peripancreatic inflammatory changes to con-firm the diagnosis. Occasionally, certain causes of pancreatitis such as com-mon duct stones, pancreatic calcifications indicating chronic pancreatitis, ora pancreatic neoplasm can be discovered. In patients who have an uncertaindiagnosis, a CT scan is helpful to identify other abdominal emergencies suchas intestinal perforation, obstruction, or mesenteric infarction.

Balthazar and colleagues [117–119] have combined the extent of pancre-atic/peripancreatic inflammatory changes and degree of pancreatic necrosisinto a CT severity index that can predict reliably the severity of disease andthe prognosis (Table 3). When intravenous contrast is contraindicated, pre-cluding an accurate evaluation of extent of necrosis, a noncontrast multisliceCT seems to be informative; patients who have peripancreatic fluid collec-tions (grade D or E on the CT severity index) had a mortality of 14%and morbidity of 54%, whereas patients who did not have fluid collections(grades A, B, or C) had no mortality and only 4% morbidity [119].

Peripancreatic fat necrosis can occur from extravasation of activatedpancreatic enzymes without pancreatic necrosis [117]. In a retrospective,cohort study, CT grading of the extent of extrapancreatic inflammation(ascites, pleural effusion, and retroperitoneal inflammation) was noted topredict local complications and persistent organ failure accurately [120].

The optimal timing of the CT scan is important. Because pancreatic necro-sis may not be appreciated by CT scan until at least 2 to 3 days after symptomonset [121], an earlier CT scan may underestimate the severity of disease.Also, a high-quality CT scan, with appropriate technique, is mandatory.

MR imaging/magnetic resonance cholangiopancreatography

Recent studies suggest that MR imaging and CT have comparable

reliability in the evaluation of severity and local complications of acutepancreatitis [122,123]. MR imaging/MRCP may offer an advantage over

Table 3

CT severity index with correlation to prognosis

CT Grading Score

Degree of

Necrosis

(%) Score

CT Severity

Index

(range)

Complications

(%)

Mortality

(%)

A: normal pancreas 0 none 0 0–3 8 3

B: edematous pancreatitis 1 none 0

C: pancreatic/peripancreatic

inflammation

2 !30 2 4–6 35 6

D: one peripancreatic fluid

collection

3 30–50 4

E: multiple peripancreatic

fluid collections

4 O50 6 7–10 92 17

Data from Refs. [117–119].

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944 ATTASARANYA et al

CT scanning, with better detection of pancreatic hemorrhage [122] and bileduct stones. Secretin-MRCP may help define pancreatic ductal anatomy,such as pancreas divisum, as well as pancreatic duct disruption undetectedby CT scan [123]. Unlike CT scan, MR imaging reliably distinguishes a pan-creatic fluid collection from liquefied necrosis [124]. The use of MR imaginghas been limited by its lack of availability on an urgent basis, its technicalinfeasibility in critically ill patients, and its variable reliability between cen-ters. Furthermore, most bile duct stones causing GSP are small (! 5 mm),and MRCP has limited accuracy in detection of these stones. One small,prospective series reported the sensitivity, specificity, and accuracy ofMRCP in detection of bile duct stones in setting of GSP to be 80%, 83%and 81%, respectively [39].

Endoscopic ultrasound

EUS is a very accurate, less invasive means to detect biliary stones. Be-

cause of its accuracy in detecting bile duct stones, EUS may serve as a usefulguide about whether to proceed with therapeutic ERCP for GSP. A normalEUS can obviate the need for ERCP because it has a high negative predic-tive value for the diagnosis of bile duct stones. The technical success rate ofearly EUS (median, ! 3 days from admission) in 123 patients suspected ofhaving GSP has been reported to be as high as 97.5% [125]. EUS followedby ERCP, if indicated, seems o be a reasonable approach, particularly incritically ill patients who have a borderline probability of bile duct stones,because ERCP is performed only if bile duct stones are confirmed by EUS.

Intraductal EUS with ERC has been shown to increase the diagnosticaccuracy of bile duct stones to 95% to 97%, whereas the accuracy ofERC alone is 87% to 90% [39,52]. It does not obviate the need forERCP, however. Although it is available at only a few centers in the UnitedStates, EUS may be useful in select patients (eg. postcholecystectomy) inwhom the detection of stones at the time of ERCP guides therapy.

Determining severity and predicting prognosis

Once acute pancreatitis has been diagnosed, the severity of disease can be

assessed to guide further management and to predict prognosis. Althoughmost patients who have acute pancreatitis have mild, self-limited disease(acute interstitial pancreatitis), which carries a mortality rate of 1% to3%, about 15% to 25% of patients develop pancreatic necrosis. If thisnecrotic tissue becomes infected, mortality approaches 30% [107].

Several clinical scoring systems have been used to predict the severity ofpancreatitis, most commonly Ranson’s criteria (overall, and biliary pancre-atitis) [126,127], Glasgow criteria [128], and APACHE-II [129]. BothRanson’s and Glasgow criteria require a 48-hour duration to complete theassessment, which is relatively long because organ failure may be evidentby this time. The APACHE-II score can be determined at admission andrepeated at 24 or 48 hours. These scoring criteria provide moderate overall

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945CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

accuracy. Because of the low prevalence of severe disease, these clinical pre-dictors yield a low positive predictive value (43%–49%) [107]. The clinicallybased Atlanta classification of acute pancreatitis is widely accepted [130].Severe pancreatitis is defined by the presence of organ failure (systolic bloodpressure ! 90 mm Hg, PaO2 % 60 mm Hg, creatinine level O 2.0 mg/dLafter rehydration, and gastrointestinal bleeding O 500 cm3/24 hours); localcomplications such as pancreatic necrosis, abscess or pseudocyst; or sys-temic complications such as laboratory evidence of disseminated intravascu-lar coagulation or a serum calcium level of 7.5 mg/dL or higher. A Ranson’sscore of 3 or higher or an APACHE II score of 8 or higher also predictssevere pancreatitis. The authors’ group does not use a formal grading systemto manage these patients.

A distinction between transient organ failure (! 48 hours) and persistentorgan failure (O 48 hours) is important [107] because the former can occurin patients who have interstitial pancreatitis with a low mortality, but thelatter has been associated with a mortality of 36% and local complicationrate of 77% [131]. Moreover, early (! 72 hours after symptom onset),progressive multiorgan organ failure is the most important predictive factorfor mortality, with a reported mortality greater than 50% in one study[132].

Obesity, defined by a body mass index of 30 or higher, was associatedwith increased morbidity and mortality of acute pancreatitis in a recentmeta-analysis of 739 patients from five studies [133]. Elevated hematocritand C-reactive protein [107] are correlated modestly with severe disease.Several markers, such as interleukins, procalcitonin, polymorphonuclearelastase, and trypsinogen activation peptide, have been evaluated in limitedstudies but are not used routinely.

Treatment

General

Adequate hydration, prevention of hypoxemia, correction of metabolic

derangements, and pain control are the mainstays of supportive care.Aggressive fluid resuscitation to preserve pancreatic microcirculation pre-vented or minimized pancreatic necrosis in an experimental model [134].Oxygen supplementation generally is recommended because most patientsrequire narcotic analgesia, which can compromise ventilatory function.Effective pain control is tailored to the individual patient. Nasogastrictube decompression is needed only in patients who have significant ileusor vomiting. Empiric proton-pump inhibitor therapy is reasonable to pre-vent stress-related mucosal injury, although firm supportive evidence islacking.

Close monitoring is needed to detect early deterioration of correctableconditions (eg. hypoxia). In patients who have severe pancreatitis, treatmentin an ICU using a multidisciplinary team approach (consisting of

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946 ATTASARANYA et al

gastroenterologists, endoscopists with expertise in ERCP, pancreatobiliarysurgeons, interventional radiologists, and a critical care team) is needed tooptimize outcome.

Nutrition

In patients who have mild pancreatitis, nutritional support is not neces-

sary because rapid recovery is expected within several days. Optimal timingfor initiating oral intake is determined according to clinical status: improv-ing pain scores, return of appetite or active bowel function, and absence ofsignificant nausea or vomiting.

In patients who have severe pancreatitis for whom prolonged pancreaticrest is expected, adequate nutritional support is needed to meet metabolicrequirements. Early enteral feeding within 48 hours after admission is welltolerated, is safer (with fewer infectious complications), and is less expensivethan parenteral nutrition [135]. In the absence of ileus, jejunal feeding ispreferable, although tube placement occasionally can be difficult. Gastricfeeding also seems to be feasible and safe [136]. Parenteral nutrition maybe considered in patients who cannot tolerate enteral feeding or when jeju-nal tube placement is not feasible technically.

Antibiotic prophylaxis

Based on a recent guideline, antibiotic prophylaxis is recommended in pa-

tients who have suspected or confirmed bile duct obstruction undergoingERCP [137]. Generally, empiric antibiotic prophylaxis is given to patientswho have GSP when early ERCP is indicated because these patients arelikely to have retained or impacted bile duct stones.

Patients who have pancreatic necrosis have a significant risk of infectiouscomplications, which constitute a major cause of death after 2 weeks ofdisease. Antibiotic prophylaxis to prevent infected pancreatic necrosis there-fore is an attractive concept. Several randomized, unblinded studies usingeither selective gut decontamination with oral antibiotics or systemic antibi-otics with various regimens in patients who have pancreatic necrosis haveshown conflicting results. One meta-analysis published in 2003 concludedthat prophylactic antibiotics significantly reduced both mortality andpancreatic sepsis [138]. Because of the heterogenous studies (eg, differentantibiotic regimens, selection criteria) included in this meta-analysis, itsreliability has been questioned. Recently, two prospective, double-blind,placebo-controlled studies showed no beneficial effects of antibiotics (cipro-floxacin/metronidazole in one; meropenem in the other) on reduction ofpancreatic infection or mortality [139,140]. Moreover, superimposed fungalinfection is a risk emerging from the prolonged use of broad-spectrum anti-biotics [107]. Currently, routine use of prophylactic antibiotics seems to beunjustified and is not recommended [107]. Rather, empiric antibiotics shouldbe used only when infected necrosis is suspected and the work-up for sepsisis pending.

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947CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

Specific therapy

Most patients who have GSP have a self-limited, uncomplicated course

with mild to moderate disease, because the offending stone passes spontane-ously into the duodenum in most patients. Routine ERCP therefore is notrecommended because of its low yield and significant risks. ERCP is usedin mild, self-limited GSP when the findings of other noninvasive tests suchas MRCP, EUS, or an intraoperative cholangiogram performed duringthe interval cholecystectomy indicate the need for definitive therapy ofbile duct stones.

Urgent endoscopic retrograde cholangiopancreatography for acutebiliary pancreatitis

The extent of pancreatic injury is related to the duration of ampullaryobstruction [141], and patients who have severe GSP are more likely tohave retained/impacted stones [142]. Therefore early restoration of ampul-lary patency at ERCP is desirable to prevent further pancreatic injury.Clinically, persistent severe pain, progressive rise of liver function tests orof the serum lipase/amylase level during the 24 to 48 hours after admission,and an elevation of bilirubin to more than 1.35 mg/dL on day 2 of hospital-ization have been used to predict retained bile duct stones in patients whohave GSP. These predictors have variable accuracy [143,144]. With theincreasing availability of MRCP and EUS, patients who are likely to haveretained bile duct stones requiring ERCP can be selected more precisely.

Clinical studies of the role of urgent endoscopic retrogradecholangiopancreatography in gallstone pancreatitis

Four landmark randomized, controlled trials have compared urgentERCP with conservative therapy [142,145–147]. Neoptolemos and col-leagues [142] first reported a randomized trial comparing urgent ERCPwithin 72 hours of admission with conservative therapy plus selectiveERCP after 5 days if indicated. Urgent ERCP was performed successfullyin 88% of patients, and biliary stones were documented in 19 patients(32%) in this group. In patients who had predicted severe GSP, earlyERCP led to a significant reduction in the overall complication rate and hos-pital stay compared with the control group (24% versus 61%, and 9.5 daysversus 17 days, respectively). No significant difference in mortality wasnoted between the two groups. This study demonstrated that an expertcould perform ERCP safely in the setting of acute pancreatitis.

Fan and colleagues [145] randomly assigned 195 patients who had pan-creatitis, 127 of whom had GSP, to early ERCP within 24 hours after admis-sion or to conservative therapy. Early ERCP was performed successfully in90% of patients; bile duct stones were discovered in 38%. Notably, 18 of thepatients (45%) who had predicted severe pancreatitis who were assigned toconservative therapy eventually had ERCP performed (for cholangitis/septic shock) at a median of less than 72 hours after admission. Subgroup

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948 ATTASARANYA et al

analysis of the 127 patients who had GSP demonstrated that the rate ofcomplications was significantly lower in the group receiving early ERCPthan in the control group (16% versus 33%), as was biliary sepsis (0% ver-sus 12%). The reduction in biliary sepsis was confined to those who werepredicted to have severe pancreatitis. There also was a trend toward lowermortality in the ERCP group (2% versus 8%; P ¼ .09). This study con-firmed the benefits of early ERCP in patients predicted to have severeGSP, as reported in the earlier British study [142].

A large preliminary study from Poland [146] evaluated 280 patients sus-pected of having GSP. All patients underwent duodenoscopy within 24hours of admission. Seventy-five patients were found to have impactedstones at the papilla and were treated immediately with BES. The remainderof the patients, who had a normal-appearing papilla, were assigned ran-domly to early ERCP (! 24 hours after admission) or conservative therapy.The patients who had early ERCP (including the 75 patients who impactedstones, who were immediately treated) had significantly lower complicationrates (17% versus 36%) and mortality (0% versus 7%) than the patientstreated with conservative therapy. The benefit of early ERCP was significantregardless of the severity of GSP and was most pronounced in patients whohad ERCP less than 24 hours after the onset of symptoms. This study hasnot been fully published, however, and some relevant data (eg, criteria forseverity, percentage of visualized bile duct stones) are not available. Hence,the clinical applicability of this preliminary report is limited.

The fourth study, reported by Folsch and colleagues [147], evaluated238 patients suspected of having GSP from 22 centers in Germany.Patients who had a bilirubin level greater than 5 mg/dL or high fever(O 39�C) were excluded. Patients assigned to early intervention hadERCP performed within 72 hours of symptom onset. This study did notdemonstrate a significant benefit of early ERCP in reduction of eithermorbidity or mortality. Instead, the study was terminated prematurelybecause the interim analysis demonstrated an increased mortality (7.9%versus 3.6%) and a higher rate of respiratory failure (12% versus 4.5%;P ¼ .03) in the early ERCP group. This study has been criticized, however,because of its higher rate of overall morbidity in comparison with theother three studies and an unclear association of early ERCP with respira-tory distress. The expertise of the participating centers also was questioned,because 19 of the 22 centers contributed fewer than a mean of 2 patientsper year to the trial [148].

Two subsequent meta-analyses concluded that early endoscopic therapy,particularly in patients who have severe disease, significantly reduces mor-bidity [149,150]. A significant reduction in mortality was evident onlywhen the Polish study was included in one meta-analysis [149], with thenumber needed to treat for avoidance of complication being 7.6 and thenumber needed to treat for avoidance of death being 25.6. It is difficult toestablish firm conclusions based on these meta-analyses because of the

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949CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

lack of homogeneity (eg, in selection criteria, predictors of severity, and tim-ing of intervention) among these randomized trials.

Two recent prospective, randomized studies addressing the use of earlyERCP to restore biliary patency in patients who have GSP have includedonly patients who met the preset criteria for ampullary obstruction[144,151]. Acosta and colleagues [144] randomly assigned patients suspectedof having ampullary obstruction (defined by persistent severe pain, bile-freegastric aspirate, and rising bilirubin level measured every 6 hours) to earlyERCP (within 48 hours of admission if obstruction persisted more than24 hours) versus conservative therapy with selective ERCP after morethan 48 hours. Ten percent of patients in each group had severe pancreatitis.Ampullary obstruction was confirmed by early ERCP in 13 of 14 patientswho met the criteria of persistent obstruction (11 had impacted stones atthe ampulla; 2 had papillary edema). This study was aborted prematurelyafter recruiting 61 patients because the interim analysis demonstrated thatmorbidity (29% versus 7%; P ¼ .04) and immediate complications (26%versus 3%; P ¼ .02) were significantly higher in the conservative groupthan in the early ERCP group. There were no deaths in this study. Notably,most immediate complications in this study were classified as pancreaticphlegmons, which were not fully defined.

Subsequently, Oria and colleagues [151] recruited 103 patients suspectedof having GSP who met criteria for ampullary obstruction (bilirubin levelO 1.2 mg/dL and distal bile duct diameter measured by TUS R 8 mm) with-out cholangitis. Patients were assigned randomly to early ERCP (within72 hours after admission) or to conservative therapy. Early ERCP was suc-cessful in 92% of patients. Bile duct stones were found in 66% of patients inthe early ERCP group versus 40% in the conservative group (who under-went elective cholecystectomy with intraoperative cholangiogram). Thisstudy showed no significant benefit from early ERCP in reduction of organfailure, local complications (6% versus 6%), overall morbidity (21% versus18%; P ¼ .8), and mortality (6% versus 2%; P ¼ 1). The timing of earlyERCP (within 72 hours) was relatively delayed in this study as comparedwith the former study. The validity of their criteria for biliary obstructionis unknown, because the rate of documented bile duct stones seems to besimilar to that of previous studies without the preset criteria of biliary ob-struction [150,152]. In addition, it is unclear how many patients in this studyactually had evidence of bile duct obstruction, rather than merely havingbile duct stones. The accuracy of TUS in measuring the distal bile ductalso has been questioned, particularly in the setting of acute pancreatitis,when overlying bowel gas commonly is present.

These six studies are summarized in Table 4. In summary, early ERCPseems to be beneficial, particularly if performed within 24 to 48 hours ofadmission or symptom onset in patients who have GSP and who have simul-taneous acute cholangitis or persistent biliary obstruction (persistent severepain and elevation of liver function tests). In patients who have severe,

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Table 4

Prospective randomized, controlled trials: urgent endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis (GSP)

Study

Number

of patients

Criteria

of predicted

severe GSP

Timing

of ERCP

Success rate

of early

ERCP (%)

Documented

stones at early

ERCP (%)

Complications (%) Mortality (%)

NotesERCP Control ERCP Control

Neoptolemos

et al [142]

146 O Three

modified

Glasgow’s

criteria

72 hours

after

admission

88 32 12/24a,b 12/61a,b 2 8 Decreased

morbidity in

predicted

severe GSP

Shortened

hospital stay

(9.5 days for

ERCP versus

17 days for

controls)

Fan

et al [145]

195/127

(with

GSP)

On admission:

serum urea

O 45 mg/dL or

plasma glucose

O 198 mg/dL

O Three

Ranson’s

criteria

24 hours

after

admission

90 38 16a/0a,c 33a/12a 5 9 Early ERCP

significantly

reduces

morbidity in

patients

predicted to

have severe

GSP

Nowak

et al [146]

280 Not mentioned 24 hours

after

admission

Not

mentioned

42 (impacted

stones)

17a 36a 2a 13a Decreased

complication

rate and

mortality in

both predicted

mild and

severe cases

950

ATTASARANYAet

al

Page 27: Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis

Folsch

et al [147]

121 R Three Glasgow

criteria

72 hours after

onset of

symptoms

96 46 46 51 7.9 3.6 Significantly

higher rate of

respiratory

failure in the

early ERCP

group

Acosta

et al [144]

61 Ranson’s and

Acosta criteria;

selected patients

with suspected

ampullary

obstructiond

! 48 hours

after

admission

only if

obstruction

persists O 24

hours

100 (of 14

patients

with

obstruction

O 24 hours)

93 29a 7a 0 0 Excluded

cholangitis

(biliary sepsis)

Main

complication

in control

group was

pancreatic

phlegmon

Oria

et al [151]

102 APACHE-II,

selected patients

with suspected

ampullary

obstructione

! 72 hours

after onset

of symptoms

92 66 21 18 6 2 Excluded acute

cholangitis

a Numbers are statistically significantly different.b All severity/ predicted severe.c Total complications/ biliary sepsis.d Defined by severe persisting pain, bile-free gastric aspirate, and elevated serum bilirubin.e Defined by distal bile duct measuring R 8 mm by ultrasound with a total bilirubin R 1.2 mg/dL on admission.

951

CHOLEDOCHOLIT

HIA

SIS

AND

GALLSTONEPANCREATIT

IS

Page 28: Choledocholithiasis, Ascending Cholangitis and Gallstone Pancreatitis

952 ATTASARANYA et al

nonobstructive GSP, the benefit of urgent ERCP is controversial. Practicevaries among experts and centers, and recommendations are inconsistent[49,107,113,152,153]. The authors perform urgent ERCP on selected casesin this situation when retained bile duct stones are suspected based on per-sistent elevation of liver function tests for more than 24 to 48 hours. Patientswho have spontaneously resolving liver function tests may not require ur-gent ERCP.

Finally, whether BES should be performed when bile duct stones are notvisualized is unclear, and each case should be judged individually. Becauseof possibility of overlooking tiny bile duct stones, particularly in a dilatedduct, performing BES empirically in severe GSP seems reasonable. Further-more, BES may prevent recurrent episodes of pancreatitis, particularly ifcholecystectomy cannot be performed in the near future or is impossible be-cause of the high surgical risk. Indeed, one guideline advocates BES in pa-tients who have severe GSP, regardless of the presence or absence of bileduct stones [153].

An algorithm for endoscopic intervention in acute GSP is proposed inFig. 2.

Cholecystectomy for gallstone pancreatitis

The primary objective of cholecystectomy is to prevent recurrent GSP.

Early laparoscopic cholecystectomy seems to be safe and effective in pre-venting recurrent attacks in patients who have mild GSP [154]. Early

Gallstone pancreatitis (intact gallbladder with stones)

Predicted/actual severe pancreatitis* Cholangitis no Predicted/actual mild pancreatitis yes

yes

yes

yes

yes

Early ERCP ± biliarysphincterotomy

(< 24-48 hours afteradmission)

Laparoscopic cholecystectomy withintraoperative cholangiogram (IOC)

(in the same admission)

Surgical candidate

ERCP withbiliary sphincterotomy

Follow up

Electivelaparoscopic

cholecystectomy(when pancreatitis

subsides)

Surgical candidate

Presence of bile duct stones?

Follow up

empirical

no

Persistent/progressive severe pain

Persistent liver function tests > 48 hours

no

no

no

Fig. 2. Algorithm of endoscopic therapy in acute gallstone pancreatitis.

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953CHOLEDOCHOLITHIASIS AND GALLSTONE PANCREATITIS

cholecystectomy may be unsafe in patients who have severe disease, how-ever, because overall complication rates and sepsis were significantly higherin those undergoing early surgery than in those undergoing delayed surgery(44% versus 5.5% and 47% versus 7%, respectively) [155].

Because of the high recurrence rate of GSP unless gallstones are removed,it currently is recommended that cholecystectomy should be performed inthe same hospitalization, when pancreatitis subsides, or within 2 to 4 weeksafter discharge [152,153]. Patients who have little evidence of retained ductalstones (resolved pain, fully normalized serum liver chemistries) may proceeddirectly to laparoscopic cholecystectomy and intraoperative cholangiogram.If any bile duct stones are documented, they can be managed by intraoper-ative or postoperative ERCP or by laparoscopic bile duct exploration, de-pending on the local expertise.

Gallstone pancreatitis after cholecystectomy

In patients who have had cholecystectomy, other causes such as sphincter

of Oddi dysfunction, pancreas divisum, and pancreatic neoplasms need tobe excluded. Less invasive investigations, such as MRCP or EUS, shouldbe considered to guide further management. If these tests do not confirmthe presence of common duct stones, a presumptive diagnosis of idiopathicpancreatitis should be made. Further discussion of this issue is beyond thescope of this article. Because of the frequent need for complex biliary pro-cedures, such as biliary and pancreatic manometry, and for minor/majorpancreatic sphincter therapy, and because of the high frequency of seriousprocedure-related complications, management of these patients should beundertaken by experienced hands.

Summary

Gallstone disease is encountered commonly in clinical practice. The diag-nosis of biliary stones has become less problematic with current, less-inva-sive imaging methods. The relatively invasive endoscopic techniquesshould be reserved for therapy and not used for diagnosis. Acute cholangitisand GSP are two major complications that require prompt recognition andtimely intervention to limit morbidity and prevent mortality or recurrence.Appropriate noninvasive diagnostic studies, adequate monitoring/support-ive care, and proper patient selection for invasive therapeutic proceduresare elements of good clinical practice.

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