Cholangitis & Management of Choledocholithiasis

Cholangitis & Management of Choledocholithiasis
By: Ruby Wang MS 3


* Cholangitis
o Clinical manifestations
o Diagnosis
o Treatment
* Diagnosis and management of choledocholithiasis
o Pre-operative
o Intra-operative
o Post-operative

Case
* HPI:
o 86 yo lady p/w 3-4 episodes of RUQ/mid-epigastric abdominal pain over the last year, lasting generally several hours, accompanied by occasional emesis, anorexia, and sensation of shaking chills.
o ROS: negative otherwise
* PE:
o VS: T 36.2, P98 , RR 18, BP 124/64
o Abdominal exam significant for RUQ TTP
* Labs
o AST 553, ALT 418. Alk Phos 466. Bilirubin 2.7
o WBC 30.3
* Imaging
o Abdominal US: multiple gallstones, no pericholecystic fluid, no extrahepatic/intrahepatic/CBD dilatation
Introduction
* Cholangitis is bacterial infection superimposed on biliary obstruction
* First described by Jean-Martin Charcot in 1850s as a serious and life-threatening illness
* Causes
o Choledocholithiasis
o Obstructive tumors
+ Pancreatic cancer
+ Cholangiocarcinoma
+ Ampullary cancer
+ Porta hepatis
o Others
+ Strictures/stenosis
+ ERCP
+ Sclerosing cholangitis
+ AIDS
+ Ascaris lumbricoides
Epidemiology
Pathogenesis
Clinical Manifestations
* RUQ pain (65%)
* Fever (90%)
o May be absent in elderly patients
* Jaundice (60%)
* Hypotension (30%)
* Altered mental status (10%)
Additional History
Additional Physical
Diagnosis: lab values
* CBC
o 79% of patients have WBC > 10,000, with mean of 13,600
o Septic patients may be neutropenic
* Metabolic panel
o Low calcium if pancreatitis
o 88-100% have hyperbilirubinemia
o 78% have increased alkaline phosphatase
o AST and ALT are mildly elevated
+ Aminotransferase can reach 1000U/L- microabscess formation in the liver
o GGT most sensitive marker of choledocholithiasis
* Amylase/Lipase
o Involvement of lower CBD may cause 3-4x elevated amylase
* Blood cultures
o 20-30% of blood cultures are positive
Diagnosis: first-line imaging
Ultrasonography
o Advantage:
+ Sensitive for intrahepatic/extrahepatic/CBD dilatation
# CBD diameter > 6 mm on US associated with high prevalence of choledocholithaisis
# Of cholangitis patients, dilated CBD found in 64%,
+ Rapid at bedside
+ Can image aorta, pancreas, liver
+ Identify complications: perforation, empyema, abscess
o Disadvantage
+ Not useful for choledocholithiasis:
# Of cholangitis patients, CBD stones observed in 13%
+ 10-20% falsely negative - normal U/S does not r/o cholangitis
# acute obstruction when there is no time to dilate
# Small stones in bile duct in 10-20% of cases

CT
o Advantages
+ CT cholangiograhy enhances CBD stones and increases detection of biliary pathology
# Sensitivity for CBD stones is 95%
+ Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscess
+ Can visualize other pathologies- cholangitis: diverticuliits, pyelonephritis, mesenteric ischemia, ruptured appendix
o Disadvantages
+ Sensitivity to contrast
+ Poor imaging of gallstones
Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
o Advantage
o Disadvantage:
Endoscopic retrograde cholangiopancreatography (ERCP)

Medical Treatment
* Resucitate, Monitor, Stabilize if patient unstable
o Consider cholangitis in all patients with sepsis
* Antibiotics
o Empiric broad-spectrum Abx after blood cultures drawn
Surgical treatment
* Endoscopic biliary drainage
o Endoscopic sphincterotomy with stone extraction and stent insertion
* Surgery
o Emergency surgery replaced by non-operative biliary drainage
o Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal
o Elective surgery: low M & M compared with emergency survey
o If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration
Our case…
* Condition:
* ERCP attempted
* Laparoscopic cholecystectomy planned
o Dissection of triangle of Calot
o Cystic duct and artery visualized and dissected
o Cystic duct ductotomy
o Insertion of cholangiogram catheter advanced and contrast bolused into cystic duct for IOC
* Intraoperative cholangiogram
o Several common duct filling defects consistent with stones
o Decision to proceed with CBD exploration

Choledocholithiasis
* Choledocholithiasis develops in 10-20% of patients with gallbladder disease
* At least 3-10% of patients undergoing cholecystectomy will have CBD stones

Pre-op diagnosis & management
o Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP
+ High risk (>50%) of choledocholithiasis:
# clinical jaundice, cholangitis,
# CBD dilation or choledocholithiasis on ultrasound
# Tbili > 3 mg/dL correlates to 50-70% of CBD stone
+ Moderate risk (10-50%):
# h/o pancreatitis, jaundice correlates to CBD stone in 15%
# elevated preop bili and AP,
# multiple small gallstones on U/S
+ Low risk (<5%): # large gallstones on U/S # no h/o jaundice or pancreatitis, # normal LFTs o Treatment: + ERCP + Surgery Intra-op diagnosis and management * Diagnosis: intraoperative cholangiography (IOC) o Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects. o Detect CBD stones o Potentially identify bile duct abnormalities, including iatrogenic injuries o Sensitivity 98%, specificity 94% o Morbidity and mortality low * Treatment o Open CBD exploration + Most surgeons prefer less invasive techniques o Laparoscopic CBD exploration + via choledochotomy: CBD dilatation > 6mm
+ via cystic duct (66-82.5%)
+ CBD clearance rate 97%
+ Morbidity rate 9.5%
+ Stones impacted at Sphincter of Oddi most difficult to extract
o Intraoperative ERCP

Early years: Open CBD exploration & Introduction of endoscopic sphincterotomy
* 1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon
o Kocherization of duodenum and short longitudinal choledochotomy
o Stones removed with palpation, irrigation with flexible catheters, forceps,
o Completion with T-tube drainage
o For many years, this was the standard treatment for cholecystocholedocholithiasis
* 1970s, endoscopic sphincterotomy (ES)
o Gained wide acceptance as good, less invasive, effective alternative
o In patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choice

Open surgery vs Endoscopic sphincterotomy
* In patients with intact gallbladders, ES or open choledochotomy?
o Design: 237 patients with CBD stone and intact gallbladders, 66% managed with ES and rest with open choledochotomy
o Results: No significant difference in morbidity and mortality rates
+ Lower incidence of retained stones after open choledochotomy
o Conclusion: open surgery superior to ES in those with intact gallbladders
* Is ES followed by open CCY superior to open CCY+ CBDE?
o Results: Initial stone clearance higher with open surgery
* Cochraine database of systematic reviews
* In patients with severe cholangitis, open or ES?

Laparoscopic CBD Exploration
* In 1989, laparoscopic removal of gallbladder replaced open surgery
o In the past decade, laparoscopic CBD exploration (LCBDE) developed
* Techniques
o IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones
o Choledochotomy
o Transcystic approach
* Results
Post-op Diagnosis and Management
* T-tube cholangiography
* ERCP
In summary
* Non-surgical care first line
* Surgical Care if endoscopy and IR drainage fail
* Open procedure
* Cholecystectomy
* CBD exploration

Cholangitis & Management of Choledocholithiasis.ppt