Diagnosis and management of cholecystitis and … · Natural history and prevalence of...

Gastroenterol Clin N Am

32 (2003) 1145–1168

Diagnosis and management ofcholecystitis and cholangitis

Ian F. Yusoff, MBBSa, Jeffrey S. Barkun, MD, MScb,Alan N. Barkun, MD, MScc,*

aMcGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, CanadabDepartment of Surgery, Royal Victoria Hospital, McGill University Health Centre,

Montreal, Quebec, Canada H4Y 1S1cDivision of Gastroenterology, McGill University Health Centre, Montreal General Hospital,

Room D7.148, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada

The main biliary tract emergencies are acute cholecystitis, ascendingcholangitis, and acute pancreatitis. These conditions usually arise asa consequence of calculi obstructing the biliary tree or gallbladder. Lessfrequently they may result from benign or malignant strictures of the biliarytree, biliary tree manipulation, or biliary sludge [1]. Despite therapeuticadvances these conditions still cause significant morbidity and mortality,particularly in the elderly [2]. This article reviews acute cholecystitis andcholangitis with a focus on the clinical presentation, diagnosis, and state-of-the-art management. Acute pancreatitis is dealt with elsewhere in this issue.

Acute calculous cholecystitis (ACC)

Acute cholecystitis is an acute inflammation of the gallbladder. Gall-stones are present in over 90% of cases, and cause persistent obstruction ofthe gallbladder outlet because of impaction in the neck of the gallbladder,Hartmann’s pouch, or cystic duct [2,3]. In the remaining 5% to 10% ofcases, gallstones are not identified, so-called ‘‘acalculous cholecystitis’’ [4].

Dr. Yusoff is an Amy and Athelstan Saw Fellow of the Faculty of Medicine and

Dentistry, The University of Western Australia.

Dr. Alan Barkun is a (Chercheur Clinicien Boursier) Senior Research Scholar of the

Fonds de la Recherche en Sante du Quebec.

* Corresponding author.

E-mail address: [email protected] (A.N. Barkun).

0889-8553/03/$ - see front matter � 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S0889-8553(03)00090-6

mailto:[email protected]

1146 I.F. Yusoff et al / Gastroenterol Clin N Am 32 (2003) 1145–1168

Natural history and prevalence of cholelithiasis and cholecystitis

Gallstones are ubiquitous; however, because most patients are asymp-tomatic, their precise incidence is uncertain. It is estimated that 10% to 15%of the United States adult population have gallstones [5], and studies fromother westernized societies describe a prevalence of 5% to 20% [6–8]. Onlya minority of patients with gallstones become symptomatic or developscholecystitis [9]. The GREPCO investigators estimated the cumulativeprobability of developing a complication in patients with asymptomaticcholelithiasis after 10 years of follow-up was 3% [10] and other studies haveconfirmed a low rate of 0.5% to 3% per year of developing complications[9,11–13]. Once the patient is symptomatic, the rate of biliary complicationsrises [9,10,12,13]. The natural history may be less benign in selectedsubgroups, such as diabetics and organ transplant recipients [14]. Becausethe epidemiology and natural history of gallstones is different in Asianpopulations, this discussion is largely limited to Westernized societies [6].

Pathophysiology

The initial event in ACC is believed to be obstruction to gallbladderdrainage [3]. This causes an increase in intraluminal pressure, gallbladderdistention, and wall edema that may progress to venous and lymphaticobstruction, ischemia, and necrosis. A number of potential mediators havebeen identified including cholesterol-supersaturated bile, lysolecithin,phospholipase A, and prostaglandins [2,3,6]. Enhanced production ofprostaglandins is believed to play a key role in mediating inflammation, andagents that reduce prostaglandin production have been shown to block theinflammatory response and reduce the pain of cholecystitis [15,16]. Bile issterile in the early stages of acute cholecystitis and infection is believed to bea secondary event [17,18]. Indeed, although ACC is often considered aninfection, bile cultures are positive only in 20% to 75% of patients [17–19].The organisms most commonly cultured are enteric bacteria includingEscherichia coli, Klebsiella, and Enterococcus [17–19].

Clinical presentation

Patients with ACC usually present with abdominal pain associated withfever, nausea, and vomiting. Pain and tenderness are usually localized to theright upper quadrant and the pain may radiate to the back, right scapula, orright clavicular area [2,20]. Three quarters of patients with ACC reporta previous attack of biliary colic [21]. The pain is distinguished from biliarycolic by its prolonged duration and the presence of Murphy’s sign (wheremid inspiration is inhibited by pain on palpation of the right upperquadrant). Singer et al [22] found that a positive Murphy’s sign was highlysensitive (97%) and predictive (positive predictive value 93%) of ACC.

1147I.F. Yusoff et al / Gastroenterol Clin N Am 32 (2003) 1145–1168

Presentation in elderly patients may be atypical. Hafif et al [23] reported thatamong 131 patients over 70 years with ACC, right upper quadrant pain wasabsent in 27% and fever was absent in 45% [23].

Diagnosis

The combination of prolonged, constant right upper quadrant pain andtenderness with fever are highly suggestive of ACC. A leukocytosis withincreased neutrophils and band forms is usually present. There may be mildelevation of the transaminases or bilirubin. A significantly elevated bilirubinshould raise the possibility of choledocholithiasis or Mirrizzi syndrome(obstruction of the common hepatic duct by a calculus impacted inHartmann’s pouch) (Fig. 1) [3,24]. The diagnosis can usually be made byeither ultrasound scanning or biliary scintigraphy. Ultrasonography ishighly sensitive and specific for the presence of gallstones greater than 2 mm,but does not always confirm the diagnosis of ACC [6,25]. The sonographicfeatures of ACC include gallbladder wall thickening, pericholecystic fluid,

Fig. 1. Mirrizzi syndrome. Cholangiography showing stone in the gallbladder infundibulum

(solid arrow) compressing externally the proximal common bile duct (open arrow) with resulting

proximal intrahepatic bile duct dilatation.


gallbladder distention, and a sonographic Murphy’s sign (Fig. 2) [25–27].The reported test performance of ultrasound varies with sensitivities of 48%to 100% and specificities of 64% to 100%; the presence of multiple criteriaincreases its diagnostic accuracy [26–32]. Biliary scintigraphy is highlyaccurate and is the gold standard for the diagnosis of cystic ductobstruction. Multiple studies have confirmed that scintigraphy hasa sensitivity and specificity for the diagnosis of ACC of over 94% [31–36].Scintigraphy, however, displays reduced specificity in the presence of hepaticimpairment, parenteral nutrition, or when the patient is in the fasting state[2]. A positive scan may also be seen in chronic cholecystitis [6]. Scintigraphygives little information about nonobstructing cholelithiasis and cannotdetect other pathologic states. In a rigorous meta-analysis, Shea et al [37]reported that scintigraphy was more sensitive and specific than ultrasonog-raphy in ACC, and recommended it be the preferred test in patients withotherwise equivocal signs of ACC. Nonetheless, the choice of initial imagingmodality remains controversial and varies with institution. The authors’practice is to use ultrasonography as the screening test for ACC given its

Fig. 2. Cholecystitis. Ultrasonographic study of the gallbladder showing a thickened

gallbladder wall (solid arrows) and pericholecystic fluid (open arrow). Gallstones are seen in

the gallbladder (S ) with the characteristic acoustic shadowing (right brace).


relatively high accuracy, availability, portability, low cost, quickness, andability to detect other pathology. Scintigraphy is usually reserved for caseswhere the ultrasound is normal and the clinical suspicion remains high.Magnetic resonance imaging (MRI) (Fig. 3) and computed tomography(CT) as an adjunct to ultrasound have been reported as being useful in thediagnosis of ACC but scanning an acutely ill patient may be difficult and theadded time and expense are infrequently justified [30,38].

Management

The immediate management of ACC includes having the patient fast;fluid and electrolyte resuscitation; and parental (narcotic) analgesia. If thepatient is vomiting, or if there is evidence of an ileus or gastric distention,nasogastric tube placement is appropriate [1]. Indomethacin has beenreported to reverse the inflammatory changes in ACC and improvegallbladder contractility when given early, and diclofenac has been reportedto reduce the rate of progression to ACC in patients with symptomatic

Fig. 3. Cholecystitis. MRI study (heavily T2-weighted) showing a thickened gallbladder wall

(A, solid arrows), sloughed mucosa in the gallbladder lumen (A, open arrow), as well as

pericholecystic fluid (B, open arrow).


gallstones; however, neither of these agents is used widely for this purpose[15,16,39]. Intravenous antibiotics are usually commenced empirically whenthere are systemic signs (eg, high fever, tachycardia, and hypotension) or ifthere has been no improvement over 12 hours with conservativemanagement [3]. The favorable results of antibiotic treatment that reducesseptic complications seems to depend more on adequate serum rather thantissue concentrations [30]. The choice of antibiotic varies with localexperience and patterns of bacterial resistance. Single-agent therapy withan extended spectrum cephalosporin provides safe, appropriate coverage inmost cases; however, in severe or high-risk cases, anaerobe cover is required(ie, by adding a nitroimidazole) [41,42]. In patients undergoing earlyuncomplicated cholecystectomy, prolonging the antibiotic course for morethan 1 day postoperatively has not shown to be of benefit [43]. It must beemphasized that the optimal therapy in ACC is surgery, not antibiotictherapy.

Cholecystectomy

Surgical cholecystectomy has been the treatment of choice for ACC sinceLangenbuch first described it in 1882. Key issues regard the timing and thetype of surgery and the treatment of those unfit for surgery. Approximately20% of patients with ACC require emergency surgery because of clinicaldeterioration or other features of complicated disease, such as peritonitis orperforation [2,3]. If the nature of the symptoms is uncertain, exploratorysurgery may be indicated [6]. For the remaining patients, early surgery hasbeen shown to be superior to delayed surgery. Six randomized controlledtrials before and after the advent of laparoscopic cholecystectomy (LC) havecompared early surgery (within days of admission) with delayed surgery(performed 6 to 8 weeks after the event) [4–49]. These studies have foundthat mortality and complication rates of early cholecystectomy are nodifferent than for delayed surgery, and that early surgery is preferablebecause of reduced total hospitalization costs and morbidity becauseapproximately 10% to 25% of patients are admitted with recurrentcomplications of gallstone disease.

Laparoscopic cholecystectomy has changed the approach to biliarydisease in the last two decades and it has been become the procedure ofchoice for elective cholecystectomy. Three randomized controlled trials[48–50] and multiple nonrandomized trials [51–56] studied the use of LC inACC. These trials confirm that early LC is a safe and feasible optionin ACC. Furthermore, these trials suggest LC within 48 to 72 hours ofpresentation (early surgery) is preferable to surgery after 3 to 5 days ofconservative therapy (interval surgery) and surgery delayed 6 to 12 weeksafter the attack (delayed surgery). The main reason for this conclusion isreduced conversion rates in the early surgery group when compared withthe interval surgery group and reduced hospital stay in the early surgery


group. Indeed, early in the course of ACC inflammation and fibrosis arelimited and tissues planes are easier to find, facilitating laparoscopicdissection. There may, however, be an increased risk of gallstone spillagewith LC and this may increase the potential risk of subsequent abscessformation [57].

Percutaneous cholecystostomy

In high-risk patients, where the risks of surgery may outweigh thebenefits, percutaneous cholecystostomy has been reported as an acceptableoption with technical success in most series of over 90% [58–64]. Thisprocedure can be performed at the bedside under ultrasound control andgives clinical improvement in 75% to 90% of patients with reportedmortality rates of 5% to 20% (usually related to underlying condition)[58,59,63,64]. An incomplete or poor response after 48 hours should prompta search for alternate sources of sepsis, complications, or tube dislodgment[3]. Once the patient has recovered, elective cholecystectomy should beperformed [65]. An attempt at elective LC is reasonable in this setting[64,66,67]. Alternatively, if the patient remains unfit for surgery, percuta-neous extraction of the calculi subsequently can be performed underradiologic or cholecystoscopic guidance [62,68,69]. In selected casesgallstone dissolution (with methyl tert-butyl ether) and disruption (withextracorporeal lithotripsy) have been reported [70,71].

Outcomes and complications of ACC

The reported mortality rate of ACC treated with LC is less than 0.5%with reported morbidity rates of 5% to 20% [48,49,52–55,72–75]. A numberof complications of ACC may occur including gallbladder perforation,gallbladder gangrene, emphysematous cholecystitis, and empyema. Thepresence of any of these calls for urgent surgery. Risk factors forcomplications include advanced age; male gender; and associated diseases,such as diabetes, high temperature, and significant leukocytosis [76].Gangrenous cholecystitis occurs in 2% to 30% of cases of ACC [3,76].Perforation of the gallbladder is present in 3% to 10% of patients with ACC[2]; the most common form of perforation is subacute, with walling off of theprocess as a pericholecystic abscess [77]. Free perforation is less common;occurring usually in institutionalized patients, it presents with generalperitonitis, and has a high mortality rate [77]. Emphysematous cholecystitisis an uncommon condition occurring when there is secondary infection ofthe gallbladder wall with gas-forming organisms. It is most common inelderly, diabetic men and it is treated with immediate administration ofantibiotics (directed at anaerobes, coliforms, and clostridia species) andurgent surgery because of the high incidence of free perforation [6]. Aclinical algorithm for the management of ACC is presented in Fig. 4.


Acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is an acute inflammation of thegallbladder in the absence of demonstrable cholelithiasis [78]. It has beensuggested that a more appropriate name is ‘‘necrotizing cholecystitis’’ todistinguish it as a distinct entity [79]. AAC accounts for 2% to 12% ofall cases of cholecystitis, and in the United States 5% to 10% ofcholecystectomies are performed for AAC [4,78,80]. AAC most frequentlyoccurs in those who are critically ill from trauma, sepsis, or burns [4,78,80].Compared with ACC, AAC tends to have a more complicated course anda higher morbidity and mortality [80]. Reported mortality rates range from10% to 50%, in part because of the severity of the underlying disease[78,80]. Other reported risk factors include vascular disease, male gender,systemic vasculitides, HIV infection, diabetes mellitus, acute renal failure,immunosuppression, prolonged fasting, and total parenteral nutrition[78,80–82]. It has also been reported in patients without identifiable riskfactors [83,84].

Pathophysiology

The pathogenesis of AAC is likely multifactorial with gallbladder stasis,paresis, and ischemia possibly playing a role [1,78]. Most patients with thiscondition have fasted for prolonged periods, are immobile, and often have

Fig. 4. Clinical algorithm for the management of ACC.


experienced hemodynamic instability, and over 70% may have associatedatherosclerotic disease [82]. It is postulated that concentrated, stagnant bileand reduced gallbladder perfusion lead to a chemical and ischemic injury tothe gallbladder epithelium [78]. Cholecystectomy specimens from patientswith AAC (but not ACC) demonstrate impaired gallbladder microcircula-tion suggesting that splanchnic vasoconstriction or intravascular coagula-tion may be important events [85,86]. As in ACC, infection is thought to bea secondary event [17].

Clinical presentation and diagnosis

The clinical features of AAC may be the same as ACC; however, some orall of these features may be absent [87]. Indeed, pyrexia may be the onlysymptom, and up to 75% of cases may initially not have symptomsreferable to the right upper quadrant [78]. Diagnostic tests used are thoseoutlined for ACC. Ultrasound is usually the first line of investigationbecause it is widely available, can be performed at the bedside, and candetect concomitant lesions [3,87]. The sonographic features are similar tothose of ACC, but without calculi [87,88]. Reports of ultrasound sensitivityhave varied from 29% to 92% with specificity being over 90% [80,88,89].CT is often performed because it is superior to sonography in detectingother intra-abdominal pathology [90]. The role of hepatobiliary scintigra-phy in AAC is debated [78]. It is highly sensitive in diagnosing AAC;however, it may lack specificity because fasting for prolonged periods mayresult in thick, viscous bile and a false-positive scan [4,91]. Morphine-augmented scintigraphy may overcome this shortcoming, and it maycomplement sonography in cases where the diagnosis is uncertain [80,89]. Inpractice multiple studies may be necessary before the diagnosis becomesapparent [80,89].

Treatment

Initial supportive management is similar to ACC. Thereafter themanagement depends on the patient’s condition. In patients fit for surgery,open cholecystectomy (OC) has been the traditional approach [2,3,80]. LChas also been reported as an acceptable alternative in the early stages ofAAC [2,92]. In critically ill patients, cholecystostomy is often preferred.Percutaneous cholecystostomy has been reported in a number of un-controlled trials with favorable success rates [93,94]. The catheter may beleft in place for 6 to 8 weeks and if no gallbladder stones are present atpostdrainage cholangiography, the catheter is removed and cholecystectomyis usually unnecessary. Endoscopic transpapillary gallbladder drainage hasbeen described for AAC but this technique has few advantages and severalpotential disadvantages (including cost and need for sedation) comparedwith percutaneous cholecystostomy [95].


Acute cholangitis

Acute cholangitis occurs as a result of bacterial infection superimposedon obstruction of the biliary tree. Of the common complications ofgallstones, cholangitis is the most rapidly lethal entity, making accuratediagnosis and early treatment imperative [6]. Patients who fail conservativetherapy and do not have appropriate drainage have mortality ratesapproaching 100% [96–98].

Pathophysiology and etiology

Bile is normally sterile [99]. The sphincter of Oddi, bile flow, andbacteriostatic properties of bile help maintain this sterility [100]. It isbelieved that biliary obstruction reduces antibacterial defenses, causes a stateof immune dysfunction, and increases small bowel bacterial colonization[98]. Bacteria are able to gain access to the biliary tree; however, the preciseroute of infection is uncertain. Ascent from the duodenum or seedingthrough the portal vein are the most likely sources, but other possibilitiesinclude spread through the lymphatics or hepatic secretion [98,101]. Onceobstructed bile is colonized, stasis allows for enhanced bacterial multipli-cation, whereas increased ductal pressure facilitates spread into thelymphatics and bloodstream [98].

Biliary obstruction is necessary but not sufficient to cause cholangitis [6].Partial obstruction is associated with a higher rate of infection than completeobstruction, and obstruction from calculi is associated with a much higherrate of cholangitis than neoplastic obstruction (which is associated withcholangitis in about 10% of cases) (Fig. 5) [98,101]. Biliary obstruction afterbiliary intervention carries a very high risk of cholangitis [2]. The organismsmost commonly cultured in cholangitis are E coli, Enterococcus, Klebsiella,

Fig. 5. Impacted bile duct stone. Endoscopic image of a patient with acute cholangitis showing

an impacted stone in the ampulla of Vater before (A) and following endoscopic sphincterotomy

(B). (See also Color Plate 17.)


and Enterobacter [98,102]. Pseudomonas, skin, and oral flora may be foundafter biliary interventions and anaerobes are found in up to 15%, mostcommonly in elderly patients after biliary surgery [6,100,102]. The mostcommon cause of cholangitis in the United States is choledocholithiasissecondary to cholelithiasis with common bile duct stones being found in up to10% of patients who present with symptomatic gallstones [1,98]. Primary bileduct stones are unusual inNorthAmerica but are common inHongKong andSoutheast Asia where Oriental cholangiohepatitis is endemic [6]. Lesscommon causes of cholangitis include obstructing primary tumors of theampulla, bile ducts, or pancreas; metastatic tumors to the porta hepatis orperipancreatic lymph nodes; benign strictures; and primary sclerosingcholangitis. With increased biliary interventions, postprocedural cholangitisis becoming more common [2]. Rare causes of cholangitis include obstructionfrom hemobilia, parasites, and hereditary abnormalities of the biliary tree[1,100].

Clinical presentation and diagnosis

Presentation of cholangitis is variable with the classic Charcot’s triad offever, right upper quadrant pain, and jaundice present in 50% to 70% ofpatients [6,98,103,104]. Fever is usually present in 90%of cases, with jaundiceand abdominal pain present in approximately 60% and 70%, respectively[98]. A small proportion of patients present with altered mental status (10%to 20%) and hypotension (approximately 30%) (the so-called ‘‘Reynold’spentad’’ when present with Charcot’s triad) [6,98,103,104]. Right upperquadrant tenderness is present in two thirds of patients but signs of peritonealirritation are less common [1]. Severe cholangitis may be associated withhepatic microabscesses that usually carry a poor prognosis (Fig. 6).

Fig. 6. Hepatic abscesses. Patient with acute cholangitis and a cholangiogram that

demonstrates a multitude of small hepatic abscesses in continuity with the biliary tree.


The diagnosis of acute cholangitis is often made clinically but laboratoryand imaging confirmation is important to enable distinction from otherconditions, such as acute cholecystitis, hepatic abscesses, and pancreatitis.Typically, laboratory investigations reveal leukocytosis, hyperbilirubinemia,elevated alkaline phosphatase, and mild elevation of transaminases[6,98,103]. Serum amylase may be elevated in up to 30% of patients [1].Ultrasonography or CT scan are the most commonly used first-line imagingmodalities. Ultrasound is highly sensitive for cholelithiasis [37] but lesssensitive (approximately 50%) for choledocholithiasis [105]. Choledocho-lithiasis may, however, be inferred if there is associated biliary dilation inthe presence of cholelithiasis. A normal ultrasound does not rule outcholangitis [6]. Most studies suggest that CT is superior to ultrasonographyfor determining the level of biliary obstruction [106–108]. MRI and MRcholangiopancreatography are accurate for detecting choledocholithiasisand determining biliary anatomy and specific features of cholangitis havebeen described [109], but this test is probably of limited value in acutecholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) ishighly accurate for determining the cause of biliary obstruction and allowsappropriate intervention where required. Given its potential for complica-tions and availability of accurate noninvasive imaging ERCP should not beused solely as a diagnostic modality. Rather, it should be used when thelikelihood of intervention is high, as is often the case in patients withclinically suspected cholangitis. Indeed, if cholangitis is suspected ina patient with cholelithiasis and the likelihood of common bile duct stoneis high [100,110,111], the authors believe investigations should be limited (toblood tests and transabdominal ultrasound) and early referral made forERCP.

Treatment

Initial management consists of correction of fluid and electrolyte deficits;correction of coagulopathy (caused by vitamin K deficiency from prolongedjaundice or low platelets from sepsis); and analgesia. In all cases ofsuspected cholangitis, blood cultures should be obtained and empiricalantibiotics commenced. Although particular agents (eg, fluoroquinolones)have better biliary penetration, this has not been shown to be of primaryimportance in affecting outcome [98]. An aminoglycoside and ampicillin areno longer the ideal regimen because of emerging gram-negative resistanceand concerns regarding nephrotoxicity [98,112]. Multiple newer regimenshave been shown to be effective, including combination therapy with anextended-spectrum cephalosporin, metronidazole, and ampicillin; single-agent or combination fluoroquinolones; and ureidopenicillins alone or withmetronidazole [98,113–118]. The choice of agent needs to be guided by localsensitivities, costs, and the need for anaerobic coverage (eg, in the elderlyand those with biliary manipulation). The authors’ practice is to use a single


broad-spectrum agent, such as a ureidopenicillin (eg, ticarcillin andclavulanic acid) where possible. All patients with ascending cholangitisrequire biliary drainage. In patients who respond to medical therapy thismay be performed semi-electively during the same admission (and ideallywithin 72 hours). Approximately 10% to 15% of patients fail to respond(within 12 to 24 hours) or deteriorate after initial medical therapy and thesepatients need urgent biliary decompression [98,119,120]. Delay in thissituation increases the chance of an adverse outcome [121].

Endoscopic biliary drainage

An ERCP with bile duct drainage or clearance is the treatment of choicefor decompressing the biliary system in acute cholangitis (Fig. 7). It hasa success rate of 90% to 98% and is superior to surgical or percutaneousdrainage in multiple studies [122–127]. Lai et al [124] randomized 83 patientswith acute cholangitis to undergo endoscopic or surgical decompression andfound that mortality (10% versus 32%) was significantly lower in theendoscopic arm [124]. Other studies have confirmed this [123,126,128].

Fig. 7. Bile duct stones. Patient with acute cholangitis and a cholangiogram that demonstrates

multiple common bile duct stones, and a basket that has been inserted for endoscopic stone

removal (solid arrow).


ERCP has also been shown to have lower morbidity rates, shorter length ofhospitalization, and a higher definitive success rate than percutaneousdrainage [125,127].

Endoscopic options are biliary drainage with a plastic stent or nasobiliarycatheter or endoscopic sphincterotomy (ES) and bile duct clearance. In thecritically ill or in patients with a coagulopathy, there are concerns that ESmay increase the risk of complications and procedure time [98]. Althoughthis has never been shown to be the case in clinical trials the concern islegitimate, especially because biliary drainage without sphincterotomy issafe and effective in such patients [121,125,127]. In the only randomized trialdirectly to compare use of nasobiliary catheter with biliary stent for acutecholangitis, Lee et al [129] found both to be equally effective but the stentwas associated with less postprocedural discomfort and avoided thepotential inadvertent removal [129]. In patients who are not critically ill,ES and bile duct clearance should be attempted, and this is the definitiveprocedure in patients who have had a cholecystectomy. Complications ofERCP and ES include pancreatitis, bleeding, stone impaction, andperforation and occur in 5% to 10%, with bleeding being a particularproblem in those with cholangitis [130]. Antibiotics should be continuedafter successful bile duct clearance because patients remain at risk ofdeveloping cholecystitis and empyema [131]. Total duration of antibiotictherapy depends on response and the authors’ practice is to continuetherapy for 7 days. A Dutch study suggests, however, that in patients withan uncomplicated course, and good response to biliary drainage, 3 days ofantibiotic therapy may be sufficient [132].

Percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage can be performed successfullyin up to 90% of patients with biliary tract obstruction [133]. It has higherrates of morbidity (30% to 80%) and mortality (5% to 15%) thanendoscopic drainage [1,125,133,134]. Nonetheless, percutaneous trans-hepatic biliary drainage may be preferred over ERCP in specific situations,such as hepatolithiasis; intrasegmental cholangitis [135]; when the papilla isinaccessible endoscopically (eg, after Roux-en-Y formation); or when ERCPhas failed. As with ERCP, caution must be taken to correct coagulopathiespreprocedurally.

Surgical biliary drainage

Open surgery has been used to treat cholangitis for almost 100 years. Itis associated with mortality rates of up to 40%, however, and is rarely usedas the first-line method of biliary drainage [103,119,136]. When it isperformed, emergency surgery may be limited to choledochotomy, de-compression, and T-tube insertion [98,103,119]. A proportion of patients


treated endoscopically or percutaneously requires definitive surgicalintervention, and the mortality is low in patients who are able to undergothis electively [1]. A clinical algorithm for the management of cholangitis ispresented in Fig. 8.

Management of the gallbladder after bile duct clearance

Whether subsequent cholecystectomy is indicated for patients withcholelithiasis who have had an episode of cholangitis successfully treatedwith ES and bile duct clearance is a matter of debate. The rationale forproceeding to cholecystectomy is to prevent further biliary complications.Management strategies need to be individualized and guided by risk factorsfor surgery and further biliary complication. In retrospective and non-randomized prospective studies, the risk of patients with common bile ductstones developing subsequent biliary complications during follow-up hasranged from 4% to 12% [137–141]. Four randomized controlled trials havebeen reported that specifically address this issue [142–145]. Boerma et al[142] studied 120 patients aged 18 to 80 years with proved symptomaticcommon bile duct and concomitant gallbladder stones who underwent ESand bile duct clearance. Patients were randomized to LC within 6 weeks ofendoscopic stone clearance or to a ‘‘wait and see’’ approach. During a meanfollow-up period of 30 months, 47% of patients in the wait and see grouphad recurrent biliary symptoms compared with 2% in the LC group.Furthermore, 37% of the wait and see group needed cholecystectomy.Targarona et al [143] randomized 98 elderly and other high-risk patientswith symptoms likely caused by bile duct stones either to ES alone or opensurgery and found that after a mean follow-up of 17 months, biliarysymptoms recurred in 20% of the ES group and 6% of the surgery group.Hammarstrom et al [144] randomized 83 patients with bile duct stones to ESand stone removal or open surgery (cholecystectomy and bile ductexploration) and found that after more than 5 years, 20% of the ES groupunderwent cholecystectomy because of recurrent biliary symptoms, whereas2% of patients in the surgery group had recurrent symptoms from bile ductstones. During the follow-up period, nonbiliary mortality was significantlymore common in the ES group. Panis et al [145] randomized 206 patientswith common bile duct stones to endoscopic therapy alone or surgery andfound early surgery was required in 19% in the endoscopic group, whereasonly 2% of the surgical group needed reoperation. Taken together thesestudies strongly support the recommendation that patients with cholangitisshould undergo elective LC after bile duct clearance if they are fit forsurgery (unless an open approach is known to be required). This may notapply to Asian patients where bile duct stones may originate fromintrahepatic stones and hence cholecystectomy may not prevent furtherbiliary complications. Two nonrandomized prospective studies from HongKong have not shown a benefit of cholecystectomy over ES alone in


Fig. 8. Clinical algorithm for the management of ascending cholangitis. *In selected clinical

scenarios PTBD may be preferred to ERCP (see text). ERCP, endoscopic retrograde

cholangiopancreatography; ES, endoscopic sphincterotomy; ESWL, extracorporeal shock

wave lithotripsy; LC, laparoscopic cholecystectomy; PTBD, percutaneous transhepatic biliary

drainage.


preventing recurrent cholangitis or biliary complications in patients withbile duct stones [139,146]. In contrast a retrospective study from Hong Kongsuggested that patients with bile duct stones treated with ES alone had anincreased risk of recurrent biliary symptoms when compared with those whoalso underwent LC and the results of further prospective trials are awaited[147]. Similarly, a recent randomized trial from Hong Kong showed that,in patients with cholangitis and gallbladder stones but in the absence ofcommon bile duct stones, ES resulted in decreased durations of cholangitisand hospital stay, but no reduced incidence of recurrent acute cholangitis[148].

Summary

Cholelithiasis is a prevalent condition in Western populations. Mostcases are asymptomatic but complications can occur. Acute cholangitis,cholecystitis, and gallstone pancreatitis are the most common biliary tractemergencies and are usually caused by biliary calculi. Whenever possible,acute cholecystitis should be treated with early LC. AAC is an uncommoncondition usually affecting patients with significant comorbidities. Treat-ment is usually with percutaneous cholecystostomy, which often is also theonly required therapy. Endoscopic drainage is the preferred form of biliarydecompression in acute cholangitis and these patients should subsequentlyundergo elective LC unless unfit for surgery. Effective and optimal man-agement of biliary tract emergencies relies on close cooperation betweengastroenterologist, surgeon, and radiologist.

Acknowledgement

The authors thank Dr. Caroline Reinhold and Dr. Ida Khalili for theMRI images.

References

[1] Kadakia SC. Biliary tract emergencies: acute cholecystitis, acute cholangitis, and acute

pancreatitis. Med Clin North Am 1993;77:1015–36.

[2] Lillemoe KD. Surgical treatment of biliary tract infections. Am Surg 2000;66:138–44.

[3] Indar A, Beckingham I. Acute cholecystitis. BMJ 2002;325:639–43.

[4] Shapiro MJ, Luchtefeld WB, Kurzweil S, Kaminski DL, Durham RM, Mazuski JE.

Acute acalculous cholecystitis in the critically ill. Am Surg 1994;60:335–9.

[5] Gallstones and laparoscopic cholecystectomy. NIH Consensus Statement 1992;10:1–28.

[6] Horton J, Bilhartz L. Gallstone disease and its complications. In: Feldman M, Friedman

L, Sleisenger M, editors. Sleisenger and Fordtran’s gastrointestinal and liver disease:

pathophysiology, diagnosis, management. Philadelphia: WB Saunders; 2002. p. 1065–90.

[7] Bates T, Harrison M, Lowe D, Lawson C, Padley N. Longitudinal study of gall stone

prevalence at necropsy. Gut 1992;33:103–7.

[8] Ingelfinger F. Digestive disease as a national problem, V. Gastroenterology 1968;55:102–4.


[9] Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg

1993;165:399–404.

[10] Attili A, De Santis A, Capri R. The natural history of gallstones: the GREPCO

experience. Hepatology 1995;21:656–9.

[11] Thistle J, Cleary P, Lachin J, Tyor M, Hersh T. The natural history of cholelithiasis: the

National Cooperative Gallstone Study. Ann Intern Med 1984;101:171–5.

[12] Gracie W, Ransohoff D. The natural history of silent gallstones: the innocent gallstone is

not a myth. N Engl J Med 1982;307:798–800.

[13] McSherry C, Ferstenberg H, Calhoun W, Lahman E, Virshup M. The natural history of

diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann Surg

1985;202:59–63.

[14] Schwesinger WH, Diehl AK. Changing indications for laparoscopic cholecystectomy:

stones without symptoms and symptoms without stones. Surg Clin North Am 1996;

76:493–504.

[15] Myers SI, Bartula L. Human cholecystitis is associated with increased gallbladder

prostaglandin I2 and prostaglandin E2 synthesis. Hepatology 1992;16:1176–9.

[16] Goldman G, Kahn PJ, Alon R, Wiznitzer T. Biliary colic treatment and acute cholecystitis

prevention by prostaglandin inhibitor. Dig Dis Sci 1989;34:809–11.

[17] Claesson BE, Holmlund DE, Matzsch TW. Microflora of the gallbladder related to

duration of acute cholecystitis. Surg Gynecol Obstet 1986;162:531–5.

[18] Claesson BE. Microflora of the biliary tree and liver: clinical correlates. Dig Dis

1986;4:93–118.

[19] Kuo CH, Changchien CS, Chen JJ, Tai DI, Chiou SS, Lee CM. Septic acute cholecystitis.

Scand J Gastroenterol 1995;30:272–5.

[20] Kalloo AN, Kantsevoy SV. Gallstones and biliary disease. Prim Care 2001;28:591–606.

[21] Raine PA, Gunn AA. Acute cholecystitis. Br J Surg 1975;62:697–700.

[22] Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among

clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute

cholecystitis. Ann Emerg Med 1996;28:267–72.

[23] Hafif A, Gutman M, Kaplan O, Winkler E, Rozin RR, Skornick Y. The management of

acute cholecystitis in elderly patients. Am Surg 1991;57:648–52.

[24] Hammarstrom L, Ranstam J. Factors predictive of bile duct stones in patients with acute

calculous cholecystitis. Dig Surg 1998;15:323–7.

[25] Carroll BA. Preferred imaging techniques for the diagnosis of cholecystitis and

cholelithiasis. Ann Surg 1989;210:1–12.

[26] Soiva M, Haveri M, Taavitsainen M, Suramo I. The value of routine sonography in

clinically suspected acute cholecystitis. Scand J Gastroenterol 1986;21:70–4.

[27] Ralls PW, Colletti PM, Lapin SA, et al. Real-time sonography in suspected acute

cholecystitis: prospective evaluation of primary and secondary signs. Radiology

1985;155:767–71.

[28] Schofield PF, Hulton NR, Baildam AD. Is it acute cholecystitis? Ann R Coll Surg Engl

1986;68:14–6.

[29] Martinez A, Bona X, Velasco M, Martin J. Diagnostic accuracy of ultrasound in acute

cholecystitis. Gastrointest Radiol 1986;11:334–8.

[30] Herlin P, Alinder G, Karp W, Holmin T. Contrast tomography of the gallbladder

wall and ultrasonography in the diagnosis of acute cholecystitis. Br J Surg 1984;71:

850–3.

[31] Samuels BI, Freitas JE, Bree RL, Schwab RE, Heller ST. A comparison of radionuclide

hepatobiliary imaging and real-time ultrasound for the detection of acute cholecystitis.

Radiology 1983;147:207–10.

[32] Kalimi R, Gecelter GR, Caplin D, et al. Diagnosis of acute cholecystitis: sensitivity of

sonography, cholescintigraphy, and combined sonography-cholescintigraphy. J Am Coll

Surg 2001;193:609–13.


[33] Mauro MA, McCartney WH, Melmed JR. Hepatobiliary scanning with 99mTc-PIPIDA

in acute cholecystitis. Radiology 1982;142:193–7.

[34] Szlabick RE, Catto JA, Fink-Bennett D, Ventura V. Hepatobiliary scanning in the

diagnosis of acute cholecystitis. Arch Surg 1980;115:540–4.

[35] Carr TG, Kazarian KK, Smego DR, Barone JE. Radionuclide cholescintigraphy in

patients with suspected biliary tract obstruction. Am Surg 1991;57:673–5.

[36] Cabellon S Jr, Brown JM, Cavanaugh DG. Accuracy of the hepatobiliary scan in acute

cholecystitis. Am J Surg 1984;148:607–8.

[37] Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and

specificity in suspected biliary tract disease. Arch Intern Med 1994;154:2573–81.

[38] Park MS, Yu JS, Kim YH, et al. Acute cholecystitis: comparison of MR cholangiography

and US. Radiology 1998;209:781–5.

[39] Akriviadis EA, Hatzigavriel M, Kapnias D, Kirimlidis J, Markantas A, Garyfallos A.

Treatment of biliary colic with diclofenac: a randomized, double-blind, placebo-

controlled study. Gastroenterology 1997;113:225–31.

[40] Jarvinen H, Renkonen OV, Palmu A. Antibiotics in acute cholecystitis. Ann Clin Res

1978;10:247–51.

[41] Bjorvatn B. Cholecystitis–etiology and treatment–microbiological aspects. Scand J

Gastroenterol Suppl 1984;90:65–70.

[42] Yellin AE, Berne TV, Appleman MD, et al. A randomized study of cefepime versus the

combination of gentamicin and mezlocillin as an adjunct to surgical treatment in patients

with acute cholecystitis. Surg Gynecol Obstet 1993;177:23–9; discussion 35–40.

[43] Lau WY, Yuen WK, Chu KW, Chong KK, Li AK. Systemic antibiotic regimens for acute

cholecystitis treated by early cholecystectomy. Aust N Z J Surg 1990;60:539–43.

[44] Linden W, Sunzel H. Early versus delayed operation for acute cholecystitis: a controlled

trial. Am J Surg 1970;120:7–13.

[45] McArthur P, Cuschieri A, Sells R, Shields R. Controlled clinical trial comparing early

with interval cholecystectomy for acute cholecystitis. Br J Surg 1975;68:850–2.

[46] Lahtinen J, Alhava EM, Aukee S. Acute cholecystitis treated by early and delayed

surgery: a controlled clinical trial. Scand J Gastroenterol 1978;13:673–8.

[47] Jarvinen H, Hastbacka J. Early cholecystectomy for acute cholecystitis: a prospective

randomized trial. Ann Surg 1980;191:501–5.

[48] Lai PB, Kwong KH, Leung KL, et al. Randomized trial of early versus delayed

laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1998;85:764–7.

[49] Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus

delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998;227:461–7.

[50] Chandler CF, Lane JS, Ferguson P, Thompson JE, Ashley SW. Prospective evaluation of

early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis.

Am Surg 2000;66:896–900.

[51] Brodsky A, Matter I, Sabo E, Cohen A, Abrahamson J, Eldar S. Laparoscopic

cholecystectomy for acute cholecystitis: can the need for conversion and the probability of

complications be predicted? A prospective study. Surg Endosc 2000;14:755–60.

[52] Willsher PC, Sanabria JR, Gallinger S, Rossi L, Strasberg S, Litwin DE. Early

laparoscopic cholecystectomy for acute cholecystitis: a safe procedure. J Gastrointest Surg

1999;3:50–3.

[53] Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the

optimal timing for operation? Arch Surg 1996;131:540–4; discussion 544–5.

[54] Pessaux P, Tuech JJ, Rouge C, Duplessis R, Cervi C, Arnaud JP. Laparoscopic

cholecystectomy in acute cholecystitis: a prospective comparative study in patients with

acute vs. chronic cholecystitis. Surg Endosc 2000;14:358–61.

[55] Pessaux P, Regenet N, Tuech JJ, Rouge C, Bergamaschi R, Arnaud JP. Laparoscopic

versus open cholecystectomy: a prospective comparative study in the elderly with acute

cholecystitis. Surg Laparosc Endosc Percutan Tech 2001;11:252–5.


[56] Rattner D, Ferguson C, Warshaw A. Factors associated with successful laparoscopic

cholecystectomy for acute cholecystitis. Ann Surg 1993;217:233–6.

[57] Strasberg SM.Laparoscopic biliary surgery.Gastroenterol ClinNorthAm1999;28:117–32.

[58] Boland G, Lee M, Leung J, Mueller P. Percutaneous cholecystostomy in critically ill

patients: early response and final outcomes in 82 patients. AJR Am J Roentgenol

1994;163:339–42.

[59] Borzellino G, de Manzoni G, Ricci F, Castaldini G, Guglielmi A, Cordiano C. Emergency

cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the

elderly. Br J Surg 1999;86:1521–5.

[60] Hamy A, Visset J, Likholatnikov D, et al. Percutaneous cholecystostomy for acute

cholecystitis in critically ill patients. Surgery 1997;121:398–401.

[61] Hultman CS, Herbst CA, McCall JM, Mauro MA. The efficacy of percutaneous

cholecystostomy in critically ill patients. Am Surg 1996;62:263–9.

[62] Lee KT, Wong SR, Cheng JS, Ker CG, Sheen PC, Liu YE. Ultrasound-guided

percutaneous cholecystostomy as an initial treatment for acute cholecystitis in elderly

patients. Dig Surg 1998;15:328–32.

[63] Patel M, Miedema BW, James MA, Marshall JB. Percutaneous cholecystostomy is an

effective treatment for high-risk patients with acute cholecystitis. Am Surg 2000;66:33–7.

[64] Berber E, Engle KL, String A, et al. Selective use of tube cholecystostomy with interval

laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 2000;135:341–6.

[65] Schwesinger WH, Sirinek KR, Strodel WE III. Laparoscopic cholecystectomy for biliary

tract emergencies: state of the art. World J Surg 1999;23:334–42.

[66] Patterson EJ, McLoughlin RF, Mathieson JR, Cooperberg PL, MacFarlane JK. An

alternative approach to acute cholecystitis: percutaneous cholecystostomy and interval

laparoscopic cholecystectomy. Surg Endosc 1996;10:1185–8.

[67] Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous

transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill

patients with acute calculus cholecystitis. Am J Surg 2002;183:62–6.

[68] Kim HJ, Lee SK, Kim MH, et al. Safety and usefulness of percutaneous transhepatic

cholecystoscopy examination in high-risk surgical patients with acute cholecystitis.

Gastrointest Endosc 2000;52:645–9.

[69] Hatzidakis AA, Prassopoulos P, Petinarakis I, et al. Acute cholecystitis in high-risk

patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol 2002;

12:1778–84.

[70] Neubrand M, Holl J, Sackmann M, et al. Combination of extracorporeal shock-wave

lithotripsy and dissolution of gallbladder stones with methyl tert-butyl ether: a randomized

study. Hepatology 1994;19:133–7.

[71] Howard DE, Fromm H. Nonsurgical management of gallstone disease. Gastroenterol

Clin North Am 1999;28:133–44.

[72] Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RT, Toouli J. Laparoscopic

cholecystectomy for acute inflammation of the gallbladder. Ann Surg 1993;218:630–4.

[73] Unger SW, Rosenbaum G, Unger HM, Edelman DS. A comparison of laparoscopic and

open treatment of acute cholecystitis. Surg Endosc 1993;7:408–11.

[74] Estes NC, McElhinney C, Estes MA, Opie H, Johnson M. Acute cholecystitis treated

urgently by nonselective laparoscopic cholecystectomy. Am Surg 1996;62:598–601;

discussion 601–2.

[75] Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical rates and operative

mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med

1994;330:403–8.

[76] Bedirli A, Sakrak O, Sozuer EM, Kerek M, Guler I. Factors effecting the complications in

the natural history of acute cholecystitis. Hepatogastroenterology 2001;48:1275–8.

[77] Tsai CJ, Wu CS. Risk factors for perforation of gallbladder: a combined hospital study in

a Chinese population. Scand J Gastroenterol 1991;26:1027–34.


[78] Bilhartz L. Acalculous cholecystitis, cholesterolosis, adenomyomatosis and polyps of the

gallbladder. In: FeldmanM, Friedman L, Sleisenger M, editors. Sleisenger and Fordtran’s

gastrointestinal and liver diseases: pathophysiology, diagnosis, management. Philadel-

phia: WB Saunders; 2002. p. 1106–30.

[79] Barrett D, Chadwick S, Fleming J. Acalculous cholelithiasis: a misnomer. J R Soc Med

1988;81:664.

[80] Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis:

incidence, risk factors, diagnosis, and outcome. Am Surg 1998;64:471–5.

[81] Fisher RL. Hepatobiliary abnormalities associated with total parenteral nutrition.

Gastroenterol Clin North Am 1989;18:645–66.

[82] Savoca PE, Longo WE, Pasternak B, Gusberg RJ. Does visceral ischemia play a role in

the pathogenesis of acute acalculous cholecystitis? J Clin Gastroenterol 1990;12:33–6.

[83] Parithivel VS, Gerst PH, Banerjee S, Parikh V, Albu E. Acute acalculous cholecystitis in

young patients without predisposing factors. Am Surg 1999;65:366–8.

[84] Savoca PE, Longo WE, Zucker KA, McMillen MM, Modlin IM. The increasing

prevalence of acalculous cholecystitis in outpatients: results of a 7-year study. Ann Surg

1990;211:433–7.

[85] Warren BL. Small vessel occlusion in acute acalculous cholecystitis. Surgery

1992;111:163–8.

[86] Hakala T, Nuutinen P, Ruokonen E, Alhava E. Microangiopathy in acute acalculous

cholecystitis. Br J Surg 1997;84:1249–52.

[87] Cornwell E, Rodriguez A, Mirvis S, Shorr R. Acute acalculous cholecystitis in critically

injured patients: preoperative diagnostic imaging. Ann Surg 1989;210:52–5.

[88] Molenat F, Boussuges A, Valantin V, Sainty JM. Gallbladder abnormalities in medical

ICU patients: an ultrasonographic study. Intensive Care Med 1996;22:356–8.

[89] Mariat G, Mahul P, Prev TN, et al. Contribution of ultrasonography and cholescintig-

raphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients.

Intensive Care Med 2000;26:1658–63.

[90] Blankenberg F, Wirth R, Jeffrey RB Jr, Mindelzun R, Francis I. Computed tomography

as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis. Gastrointest

Radiol 1991;16:149–53.

[91] Fink-Bennet D, Balan H, Robbins T, Tsai D. Morphine-augmented cholescintigraphy: its

efficacy in detecting acute cholecystitis. J Nucl Med 1991;32:1231–5.

[92] Arnot RS. Laparoscopy and acalculous cholecystitis. Aust N Z J Surg 1994;64:405–6.

[93] Shirai Y, Tsukada K, Kawaguchi H, Ohtani T, Muto T, Hatakeyama K. Percutaneous

transhepatic cholecystostomy for acute acalculous cholecystitis. Br J Surg 1993;80:1440–2.

[94] Kim KH, Sung CK, Park BK, Kim WK, Oh CW, Kim KS. Percutaneous gallbladder

drainage for delayed laparoscopic cholecystectomy in patients with acute cholecystitis.

Am J Surg 2000;179:111–3.

[95] Johlin FC Jr, Neil GA. Drainage of the gallbladder in patients with acute acalculous

cholecystitis by transpapillary endoscopic cholecystotomy. Gastrointest Endosc 1993;39:

645–51.

[96] Andrew DJ, Johnson SE. Acute suppurative cholangitis, a medical and surgical

emergency: a review of ten years experience emphasizing early recognition. Am J

Gastroenterol 1970;54:141–54.

[97] Dow RW, Lindenauer SM. Acute obstructive suppurative cholangitis. Ann Surg

1969;169:272–6.

[98] Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am

2000;14:521–46.

[99] Csendes A, Fernandez M, Uribe P. Bacteriology of the gallbladder bile in normal subjects.

Am J Surg 1975;129:629–31.

[100] Carpenter HA. Bacterial and parasitic cholangitis. Mayo Clin Proc 1998;73:473–8.

[101] Cetta F. The route of infection in patients with bactibilia. World J Surg 1983;7:562.


[102] Shimada K, Noro T, Inamatsu T, Urayama K, Adachi K. Bacteriology of acute

obstructive suppurative cholangitis of the aged. J Clin Microbiol 1981;14:522–6.

[103] Boey JH, Way LW. Acute cholangitis. Ann Surg 1980;191:264–70.

[104] O’Connor MJ, Schwartz ML, McQuarrie DG, Sumer HW. Acute bacterial cholangitis:

an analysis of clinical manifestation. Arch Surg 1982;117:437–41.

[105] Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the

detection of choledocholithiasis. AJR Am J Roentgenol 1984;142:725–8.

[106] Baron RL, Stanley RJ, Lee JK, et al. A prospective comparison of the evaluation of

biliary obstruction using computed tomography and ultrasonography. Radiology 1982;

145:91–8.

[107] Gibson RN, Yeung E, Thompson JN, et al. Bile duct obstruction: radiologic evaluation

of level, cause, and tumor resectability. Radiology 1986;160:43–7.

[108] Pasanen PA, Partanen K, Pikkarainen P, Alhava E, Pirinen A, Janatuinen E. Diagnostic

accuracy of ultrasound, computed tomography, and endoscopic retrograde cholangio-

pancreatography in the detection of obstructive jaundice. Scand J Gastroenterol

1991;26:1157–64.

[109] Bader TR, Braga L, Beavers KL, Semelka RC. MR imaging findings of infectious

cholangitis. Magn Reson Imaging 2001;19:781–8.

[110] Menezes N, Marson LP, debeaux AC, Muir IM, Auld CD. Prospective analysis of

a scoring system to predict choledocholithiasis. Br J Surg 2000;87:1176–81.

[111] Barkun AN, Barkun JS, Fried GM, et al. Useful predictors of bile duct stones in patients

undergoing laparoscopic cholecystectomy. McGill Gallstone Treatment Group. Ann Surg

1994;220:32–9.

[112] Desai T, Tsang T. Aminoglycoside nephrotoxicity in obstructive jaundice. Am J Surg

1988;85:47–50.

[113] Leung JW, Ling TK, Chan RC, et al. Antibiotics, biliary sepsis, and bile duct stones.


[114] Thompson JE Jr, Pitt HA, Doty JE, Coleman J, Irving C. Broad spectrum

penicillin as an adequate therapy for acute cholangitis. Surg Gynecol Obstet 1990;171:

275–82.

[115] Chacon JP, Criscuolo PD, Kobata CM, Ferraro JR, Saad SS, Reis C. Prospective

randomized comparison of pefloxacin and ampicillin plus gentamicin in the treatment

of bacteriologically proven biliary tract infections. J Antimicrob Chemother 1990;26

(suppl B):167–72.

[116] Karachalios GN, Nasiopoulou DD, Bourlinou PK, Reppa A. Treatment of acute biliary

tract infections with ofloxacin: a randomized, controlled clinical trial. Int J Clin

Pharmacol Ther 1996;34:555–7.

[117] Karachalios GN, Zografos G, Patrikakos V, Nassopoulou D, Kehagioglou K. Biliary

tract infections treated with ciprofloxacin. Infection 1993;21:262–4.

[118] Sung JJ, Lyon DJ, Suen R, et al. Intravenous ciprofloxacin as treatment for patients with

acute suppurative cholangitis: a randomized, controlled clinical trial. J Antimicrob

Chemother 1995;35:855–64.

[119] Lai EC, Tam PC, Paterson IA, et al. Emergency surgery for severe acute cholangitis: the

high-risk patients. Ann Surg 1990;211:55–9.

[120] Thompson JE Jr, Tompkins RK, Longmire WP Jr. Factors in management of acute

cholangitis. Ann Surg 1982;195:137–45.

[121] Boender J, Nix GA, de Ridder MA, et al. Endoscopic sphincterotomy and biliary

drainage in patients with cholangitis due to common bile duct stones. Am J Gastroenterol

1995;90:233–8.

[122] Leung JW, Chung SC, Sung JJ, Banez VP, Li AK. Urgent endoscopic drainage for acute

suppurative cholangitis. Lancet 1989;1:1307–9.

[123] Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL. Management of acute cholangitis

and the impact of endoscopic sphincterotomy. Br J Surg 1986;73:988–92.


[124] Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis.

N Engl J Med 1992;326:1582–6.

[125] Sugiyama M, Atomi Y. Treatment of acute cholangitis due to choledocholithiasis in

elderly and younger patients. Arch Surg 1997;132:1129–33.

[126] Chijiiwa K, Kozaki N, Naito T, Kameoka N, Tanaka M. Treatment of choice for

choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver

cirrhosis. Am J Surg 1995;170:356–60.

[127] Sugiyama M, Atomi Y. The benefits of endoscopic nasobiliary drainage without

sphincterotomy for acute cholangitis. Am J Gastroenterol 1998;93:2065–8.

[128] Ditzel H, Schaffalitzky de Muckadell OB. Endoscopic sphincterotomy in acute cholangitis

due to choledocholithiasis. Hepatogastroenterology 1990;37:204–7.

[129] Lee DW, Chan AC, Lam YH, et al. Biliary decompression by nasobiliary catheter or

biliary stent in acute suppurative cholangitis: a prospective randomized trial. Gastrointest

Endosc 2002;56:361–5.

[130] Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary

sphincterotomy. N Engl J Med 1996;335:909–18.

[131] Davidson BR, Neoptolemos JP, Carr-Locke DL. Endoscopic sphincterotomy for

common bile duct calculi in patients with gall bladder in situ considered unfit for

surgery. Gut 1988;29:114–20.

[132] van Lent AU, Bartelsman JF, Tytgat GN, Speelman P, Prins JM. Duration of antibiotic

therapy for cholangitis after successful endoscopic drainage of the biliary tract.


[133] Joseph PK, Bizer LS, Sprayregen SS, Gliedman ML. Percutaneous transhepatic biliary

drainage: results and complications in 81 patients. JAMA 1986;255:2763–7.

[134] Pessa ME, Hawkins IF, Vogel SB. The treatment of acute cholangitis: percutaneous

transhepatic biliary drainage before definitive therapy. Ann Surg 1987;205:389–92.

[135] Yeh YH, Huang MH, Yang JC, Mo LR, Lin J, Yueh SK. Percutaneous trans-hepatic

cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year

follow-up. Gastrointest Endosc 1995;42:13–8.

[136] Raraty MG, Finch M, Neoptolemos JP. Acute cholangitis and pancreatitis secondary to

common duct stones: management update. World J Surg 1998;22:1155–61.

[137] Hill J, Martin DF, Tweedle DE. Risks of leaving the gallbladder in situ after endoscopic

sphincterotomy for bile duct stones. Br J Surg 1991;78:554–7.

[138] Escourrou J, Cordova JA, Lazorthes F, Frexinos J, Ribet A. Early and late complications

after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder in

situ. Gut 1984;25:598–602.

[139] Lai KH, Lin LF, Lo GH, et al. Does cholecystectomy after endoscopic sphinctero-

tomy prevent the recurrence of biliary complications? Gastrointest Endosc 1999;49:

483–7.

[140] Welbourn CR, Beckly DE, Eyre-Brook IA. Endoscopic sphincterotomy without

cholecystectomy for gall stone pancreatitis. Gut 1995;37:119–20.

[141] Neoptolemos JP, Carr-Locke DL, Fraser I, Fossard DP. The management of common

bile duct calculi by endoscopic sphincterotomy in patients with gallbladders in situ. Br J

Surg 1984;71:69–71.

[142] Boerma D, Rauws EA, Keulemans YC, et al. Wait-and-see policy or laparoscopic

cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial.

Lancet 2002;360:761–5.

[143] Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic

sphincterotomy with gallbladder left in situ versus open surgery for common bile duct

calculi in high-risk patients. Lancet 1996;347:926–9.

[144] Hammarstrom LE, Holmin T, Stridbeck H, Ihse I. Long-term follow-up of a prospective

randomized study of endoscopic versus surgical treatment of bile duct calculi in patients

with gallbladder in situ. Br J Surg 1995;82:1516–21.


[145] Panis Y, Suc B, Escat J. Surgery versus endoscopic sphincterotomy for choledocholi-

thiasis: results of a prospective randomized study. Gastroenterology 1995;108:A431.

[146] Hui CK, Lai KC, Yuen MF, Ng MM, Lam SK, Lai CL. Role of cholecystectomy in

preventing recurrent cholangitis. Gastrointest Endosc 2002;56:55–60.

[147] Poon RT, Liu CL, Lo CM, et al. Management of gallstone cholangitis in the era of

laparoscopic cholecystectomy. Arch Surg 2001;136:11–6.

[148] Hui CK, Lai KC, Wong WM, Yuen MF, Lam SK, Lai CL. A randomized controlled trial

of endoscopic sphincterotomy in acute cholangitis without common bile duct stones. Gut

2002;51:245–7.

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