Nomenclature
Acute Cholangitis
Ascending Cholangitis
Bacterial / Suppurative Cholangitis
Toxic Cholangitis
Primary Choledocholithiasis
Causes of biliary obstruction in acute cholangitis
Stones - most common
Examples:
- Gallbladder stones migrated to common bile duct
- primary bile duct stones
Risks:
- Same risk factors as for gallbladder stones;
- Associated with bile duct stasis, strictures, parasites, or hemolysis
- Older age
- Hepatitis C (cholangiocarcinoma)
Most common cause of biliary obstruction with cholangitis
Neoplasms
Examples:
- Papillary tumors
- Pancreatic malignancy
- Cholangiocarcinoma
- Extrinsic compression by tumors in the hepatic hilum
Risks:
- Older age
- Hepatitis C (cholangiocarcinoma)
Biliary instrumentation increases risk for infection
Fibrotic stricture
Examples:
- Stone related
- Postsurgical
- Trauma
- Chronic pancreatitis
- Sclerosing cholangitis
Risks:
- Complicated stone disease
- History of surgery or trauma
- Alcohol, heredetary, autoimmune
- Ulcerative colitis
Acute infection is treated without surgery, while chronic management often requires surgery
Parasitic - cool pictures
Examples:
- Ascaris lumbricoides
- Clonorchis sinensis
- Opisthochis felineus
- Opisthorchis viverrini
- Fasciola hepatica
Risks
- Immigrants from endemic areas
Ascaris may have to be removed; may show only fibrosis and strictures; evidence of current parasitic infection may not be found
Primary Choledocholithiasis
Definition: Occurrence of choledocholithiasis > 2 yr after GB removal
Rare in US
Associated with biliary stasis & infection
Typically brown pigment type (soft, easily crumble)
Result of bili. deconjugation & precipitation c Ca++
Requires choledochoenterostomy to avoid 40% recurrence (must be end-to-side to avoid "sump syndrome")
Sump Syndrome
Side-to-side choledochoduodenostomy + sphincter of oddi dysfunction --> inability to clear stones, bile from the distal bile duct --> recurrent cholangitis
Secondary Choledocholithiasis
Definition: obstruction from stones that originate in GB
2-10% present at time of Cholecystectomy
1-2% retained stone rate
CBD stones occuring < 2 years/p cholecystectomy
Signs and Symptoms
Epigastric &/or RUQ pain
Back pain (scapular = cholecystitis, while R Shoulder = choledocholithiasis)
Darkened urine / whitish stool
Jaundice
Elevated BiliD, AP, GGT
Post-op Bilirubin Course
After relief of obstruction BiliT drops by ~50% within 48hr, then by 8%/day
If jaundiced for > 3 weeks, delta bilirubin forms with prolonged ½ life
May see spasm after Lap CBDE – don’t routinely check LFTs, often elevated from exploration
Be aware – fluoroquinolones can cause cholestasis
Dx
US – CBD dilatation +/- visualized stone (60%)
MRCP – 95% Sensitive, 89% Specific (overrated, weak at periduodenal region, strong with klatsin tumors)
EUS - best at periampulary area
ERCP or PTHC - usually interventional
Operative Cholangiography / Choledochoscopy
Endoscopic Choledochoscopy - spyglass
Intraop. Cholangiography
First reported by Mirizzi, Berci introduced C arm applications
92-97% successful
95%+ sensitive (= ERCP)
8-12% + IOC rate after – ERCP
Adds ~ 15 minutes to case
Associated with decreased BD Injury Rate
Risk Factors for CBD Stones
Jaundice
CBD > 7 mm
Cystic Duct > 4 mm
Small (< 3mm) stones
Large # (>11) of stones
Age > 60
Hyperbilirubinemia
AP > 150
AST > 40
ALT > 40
GGT > 40
# of risk factors, frequency of CBD stones: 0, 0; 2, 4; 4, 40; >7, 80
Laparoscopic CBD Exploration
~ 75% successful
Majority can be performed via cystic duct
Associated with shorter stays & $
Not associated c pancreatitis
100 pts c risk factors for CBD stones
40 pts c CBD stones at OR
75% successful Lap CBDE
10% Need for post-op ERCP
Endoscopic Cholangioscopy or Choledochoscopy (aka Cholangioscopy or spyglass)
Possible nonoperatively c minature endoscopes - choledochoscope)
Provides additional info in as many as 68%
Cholangitis
Presentation
Charcot’s Triad: RUQ pain (90%), fever (60-90%), jaundice (60-90%))
Reynold’s Pentad: charcot's + hypotension and mental status changes
Atypical Presentations common in elderly
Pathophysiology
Normal Biliary Pressures: 7-14 cm H20;
Increased to > 20 cm H20 with obstruction
Results in: cholangiovenous reflux of bacteria and cholangiolymphatic r3eflux of bacteria --> sepsis
Normal bile anti-infection mechanisms: sphincter of Oddi; flushing action; bacteriostatic bile salts; anti-adherence factors (IgA, mucus)
Normal bile is sterile
70% of gallstone pts have bacteria in bile
Pathophysiology of Renal Failure in Cholangitis:
Cholangitis --> sepsis, hypotension --> AKI
Cholangitis --> inc. circulating bile salts --> renal tubule damage --> AKI
Bacteriology
GNR: E. coli (25-50%), Klebsiella (15-20%), pseudomonas, enterobacter (5-10%)
Anaerobes
Enterococcus (10-20%)
Antibiotics
B-lactams (Cefotetan, Zosyn, etc…)
Fluoroquinolone + Flagyl
Carbopenems
Diagnosis
CLINICAL (+ US)
US
- Noninvasive, inexpensive, sensitive for detecting dilated ducts and gallbladder stones
- Poor sensitivity for CBD stones and for diagnosing cause and location of obstruction
- Common initial test
CT
- Noninvasive; usually good detail of location and cause of obstruction; useful when neoplasm is suspected
- Poor sensitivity for CBD
MRCP
EUS
ERCP
PTHC
Cholangitis Management
Sepsis management - supporting sepsis guidelines
Confirm the diagnosis
Provide drainage
Prevent Reoccurence
Treatment = Drainage
ERCP Decompression
ERCP c Stenting
Avoid sphincterotomy - 66 vs 34% morbidity; 32 vs 10% mortality
Aspirate prior to inject
Stage procedures with severe cholangitis
Indications for Urgent Drainage
Severe abdominal pain
Hypotension
Fever > 102 0F (39 0C)
Mental Confusion
Surgical Intervention
50% morbidity, 20% mortality when used 1st line
Increased to 91% morbidity & 55% mortality with 3 or more of the following: medical co-morbidities, pH < 7.4; Bili >9; Plt 150; alb < 3
Post ERCP Surgical Intervention
Lap or open chole best performed within 6 weeks of ERCP clearance
Late OR --> 29% intraop, 43% postop comps
Early OR --> 9% intraop, 16% postop comps
Surgical Intervention
Definitive: CBDE
Damage Control: T-tube & get out
Type I Mirizzi Syndrome
CHD obstruction due to stone impaction or severe inflammation in cystic duct neck
0.7-1.8 of all acute chole cases
Can mimic cholangitis
Treatment = Cholecystectomy
Type II Mirizzi Syndrome
Acquired cholecystocholedochal fistula / absent cystic duct
Treatment: subtotal cholecystectomy OR choledochoenterostomy
AIDS Cholangiopathy
Syndrome of biliary obstruction due to infection-related strictures
See with CD4 < 100
Prior to retrovirals was seen in ~26%
Due to Cryptosporidium &/or CMV
Medical treatment does not help c biliary sxs
AIDS Cholangiopathy
Involves papillary stenosis & sclerosing cholangiits
Present c:
Treatment: ERCP c sphincterotomy &/or stenting