Choledocholithiasis & Cholangitis

Choledocholithiasis

1. pathogenesis: CBD obstruction 2/2 stone/sludge

   • primary stones: arise w/in CBD (brown stones)

     1. color from cholesterol, more common in Asians

     2. thought to be 2/2 biliary dysmotility and infection

   • secondary stones: gallstones that lodge in CBD

2. clinical: biliary colic > 6h and labs c/w cholestasis

3. imaging

   • RUQUS (73% SN vs 91% SP)

   • MRCP

   • EUS

4. risk assessment (p1099 Table 15 ASGE 2019)

   • high probability

     1. CBD stone on RUQUS/CT

     2. acute cholangitis

     3. TBili ≥ 4.0 w/CBD dilation

   • intermediate probability

     1. abnormal LFTs

     2. age > 55-y/o

     3. TBili < 4.0 w/CBD dilation

   • low probability

     1. no predictors present

5. therapy

   • high probability: pre-op ERCP f/b lap chole

   • intermediate probability: either

     1. MRCP: if positive → pre-op ERCP f/b lap chole

     2. lap chole w/IOC: if positive: LCBDE

        • trans-cystic LCBDE

          1. 100 mL NS flush

          2. +/- glucagon 1 gm (peak IV effect in 5-20 min)

          3. +/- Fogarty balloon dilation

          4. +/- fluoroscopy-guided wire basket

          5. +/- choledochoscopy

        • trans-ductal LCBDE

          1. longitudinal choledocholithotomy

          2. f/b closure (primary vs T-tube)

          3. bailout: closure f/b ERCP or PTC

   • low probability: lap chole alone

6. complications

   • acute cholangitis (causes 28-70% of cholangitis)

   • gallstone pancreatitis (causes 40-70% of pancreatitis)

Cholangitis

(Tokyo Guidelines 2018)

1. etiology

   • choledocholithiasis (28-70%)

   • malignant stenosis (10-57%)

   • benign stenosis (5-28%)

   • PSC (0-24%)

2. clinical

   • Charcot triad (66.3% SN vs 95.1% SP): (1) jaundice, (2) RUQ pain, (3) fever

   • Reynold pentad: Charcot triad w/(4) AMS & (5) hypotension

3. diagnosis

   • suspected: ≥ 1 item in A + ≥ 1 item in B

   • definite: suspected criteria + C

A. systemic signs of inflammation

• • • • fever and/or shaking chills

      • lab evidence of inflammatory response

B. cholestasis: fever, ↑CRP, ↑WBC

• • • • jaundice (TBili ≥ 2.0)

      • ALP, GGT, AST, ALT > 1.5 × UNL

C. imaging findings c/w acute cholangitis

3. • 1. • biliary dilation (≥ 6 mm + 1 mm/decade over 60-y/o)

        • evidence of etiology (stricture, stone, stent, etc.)

4. imaging

   • RUQUS: 42% SN vs 96% SP

   • MRCP: CBD dilation, evidence of etiology (stricture, stone, stent, etc.)

5. severity

   • grade 1: not grade 2 or 3

   • grade 2: ≥ 1 of the following

     1. WBC > 12

     2. high fever ≥ 39

     3. age ≥ 75-y/o

     4. TBili ≥ 5.0

     5. Alb < 3.0

   • grade 3: ≥ 1 of the following

     1. hypotension requiring dopamine ≥ 5 mcg/kg/min or any norepinephrine

     2. AMS

     3. P/F ratio < 300

     4. oliguria or Cr > 2.0

     5. INR > 1.5

     6. Plt < 100

6. abx regimen: same as for acute cholecystitis (above)

7. therapy

   • grade 1

     1. abx/supportive tx

     2. address etiology w/wo 

     3. +/- biliary drainage

   • grade 2

     1. abx/supportive tx

     2. early biliary drainage

     3. address etiology

   • grade 3

     1. urgent biliary drainage

     2. organ support/abx

     3. address etiology