cholangitis1 fk usu
TRANSCRIPT
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CHOLANGITIS
ASRUL
MATERI KULIAH FK-USU
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PendahuluanPendahuluan
• Definisi:
Cholangitis adalah sindroma klinis yang disebabkan oleh infeksi pada sistem bilier akibat adanya hambatan aliran empedu.
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PendahuluanPendahuluanEpidemiologi : • Frekuensi
– di USA : • Relatif jarang, berhubungan dengan
penyebab obstruksi baktibilia : ERCP (1-3%)• Injeksi zat kontras secara retrograd.
– Negara2 lain: • Oriental cholangio-hepatitis endemik di As-
Teng.• Recurrent pyogenic cholangitis dengan batu
intra & extrahepatic pada 70-80% pasien & cholelithiasis pada 50-70%.
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PendahuluanPendahuluan• Mortalitas :
– Dulu : 100 % (t.u : dengan penyakit penyerta)– Sekarang : 7 - 40 %– Operasi emergensi : 17 - 40 %– Bedah Elektif : 3 %
• Ras :– Insidensi cholethiasis : Eropah Utara, Hispanik,
Amerika, Pima Indian. – Asian : batu primer CBD, e.c. infeksi, stasis
empedu, striktur & parasit. (recurrent pyogenic cholangitis)
– Afrika : sickle cell anemia
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Pendahuluan :Pendahuluan :
• Jenis kelamin :– Laki : wanita = 1:1
• Umur :– Rata-rata : umur 51 tahun– Usia tua : sering dengan batu
empedu asimtomatik– Mortalitas meningkat: penyakit
penyerta
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Etiologi :Etiologi :
• Stasis/ obstruksi empedu pada CBD : obstruksi parsial lebih sering.
• Common Bile Duct (CBD) stones :– 10-15% pasien cholecystitis : batu
CBD.– 1% pasien post cholecystectomy:
retained CBD stones. – Batu primer.
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Etiologi :Etiologi :• Penyebab lain :
– Tumor : Pancreatic cancer, Cholangiocarcinoma, tumor Portohepatis/ metastasis
– Striktur atau stenosis– Manipulasi Endoskopik : CBD Strictures/
stenosis, Inflammatory bowel disease – Choledochocele– “Sclerosing cholangitis (from biliary sclerosis)– Cacing Ascaris– “Biliary enteric anastomosis”
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Penyebab ObstruksiPenyebab Obstruksi
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Batu CBD : primer dan sekunderBatu CBD : primer dan sekunder
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Patofisiologi :Patofisiologi :Stasis atau obstruksi yang disertai oleh bakteria.
Obstruksi : t.u. batu & Stasis : strictures, stenosis,tumor atau
manipulasi endoskopik CBD.
Pasase empedu lambat (predisposisi :infeksi bakteri: v.porta,limfatik & duodenum)
Infeksi asenderen pada duktus hepatikus
Tekanan intrabilier tinggi
Infeksi biliary canaliculi, vena hepatika dan limfatik perihepatik,
yang menyebabkan bakteremia(25-40%).
Cholangitis supurativa
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Manifestasi Klinis : Klasifikasi
• Cholangitis dengan cholecystitis :(obstruksi - )– batu CBD kecil– kompresi oleh
vesica felea / KGB / inflamasi pankreas
– edema/spasme sphincter Oddi
– edema mukosa CBD– hepatitis
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Manifestasi Klinis : Klasifikasi
• Acute Non Suppurative Cholangitis
• Terdapat baktibilia tanpa pus
• Obstruksi parsial
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Manifestasi Klinis : Klasifikasi
• Äcute suppurative cholangitis
• CBD berisi pus dan terdapat bakteria
• Obstruksi parsial
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Manifestasi Klinis : Klasifikasi
• Acute Suppurative Cholangitis dengan sepsis
• Obsrtruksi total
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Bakteriologi :Bakteriologi :
Bakteri Darah Empedu• E. coli 26 % 26 %• Klebsiella spp 14 % 12 %• Enterococci 9 % 11 %• Pseudomonas spp. 9 % 5 %• Stapylococcus spp. 9 % 3 %• Enterobacter spp. 1 % 5 %• Bacteroides spp. 2 % 4 %• Clostridium spp. 0.3 % 4 %• Dapat polimikrobial
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Faktor prediktif untuk baktibilia :Faktor prediktif untuk baktibilia :
• Umur > 60 tahun• Febris > 37.3 C • Bilirubin total >
8.6 mol/L• Leukosit >
14.000/mm3
• Kanulasi bilier• Diabetes mellitus• Hyperamylasemia• Obesitas• “Recent episode of
cholecystitis / cholangitis”
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KomplikasiKomplikasi
• Sepsis berlarut
• Shock Septik
• Gagal organ ganda
• Abses hati piogenik (sering multipel)
• Peritonitis
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Diagnosis: Gejala klinikDiagnosis: Gejala klinik
• 1877 : Charcot triad : “right upper quadrant pain, fever and jaundice” (70%) & tak selalu lengkap.
• Bisa ringan, sedang, & fulminan .• Reynold's pentad : the triad + “ mental
status changes” & sepsis (shock)• Lansia: Mungkin tak bisa menunjukkan rasa
nyeri
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Diagnosis: Gejala klinikDiagnosis: Gejala klinik
• Gejala lain : Fever, chills & rigors(95%), RUQ pain (80%), diffuse abdominal pain (80%), Jaundice (80%), vomitus (50%),iritasi peritoneal (45%), Pruritus, “Acholic / hypocholic stools”, shock (5%).
• RPD : Gallstones(75%), CBD stones, Recent cholecystectomy, ERCP, cholangiogram, History of cholangitis, HIV /AIDS :infeksi cryptosporidium ?
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Diagnosis: Pemeriksaan FisikDiagnosis: Pemeriksaan Fisik
• Fever : 95% of cases, (elderly patients: may have no fever).
• RUQ pain (90%-Murphy sign)
• Mild hepatomegaly• Jaundice (80%)• Mental status changes
• Sepsis• Hypotension• Tachycardia• Septic shock (4-5%)• Peritonitis is unusual
and should lead to a search for an alternative diagnosis.
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Diagnosis: LaboratoriumDiagnosis: Laboratorium
• Darah: Leukositosis(79% > 10,000, with left shift) rata-rata 13.600 atau leukopeni(sepsis).
• AST, ALT • Fosfatase alkali : malignant vs Benign
obstruction (mean 531 vs. 278)• Bilirubin (mean : 6.6). “Malignancy” lebih
tinggi (> 12 mg%).
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Diagnosis: LaboratoriumDiagnosis: Laboratorium
• Fungsi ginjal• Elektrolit • Calcium (jika ada pancreatitis)• Prothrombin and PTT:• Memanjang : sirosis, sepsis, th/ operatif• Kultur darah (dua kali ): 20-30% positive,
kebanyakan polymicrobial• Urinalysis:biasanya normal
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Diagnosis: LaboratoriumDiagnosis: Laboratorium
• Blood Type, Screen & Crossmatch:• Amylase dan/atau Lipase:CBD bisa
menyebabkan amylase naik dan pankreatitis. Sepertiganya : mildly elevated amylase.
• Biliary Cultures: Jika drainase bilier dengan
“ interventional radiology” atau endoskopi, kultur harus dikirim.
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Diagnosis: Diagnosis: Pemeriksaan PencitraanPemeriksaan Pencitraan
• Ultra sonografi: 90 - 95 %– dilatasi CBD– batu CBD– tumor CBD atau
pankreas– batu intrahepatik– abses hepar
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Pemeriksaan Pencitraan :Pemeriksaan Pencitraan :
• Foto polos abdomenFoto polos abdomen :– 15 - 20 % batu radio-opak– Gas pada gall bladder, biliary tract
• HIDA (Technnetium-labelled hydroxy HIDA (Technnetium-labelled hydroxy imino-diacetic acid)imino-diacetic acid)– Patensi sistem bilier / bilio-digestif
• PTHC (Percutaneus Transhepatic PTHC (Percutaneus Transhepatic Cholangiography)Cholangiography)– Dilatasi intra hepatal
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Pemeriksaan Pencitraan : CT-ScanPemeriksaan Pencitraan : CT-Scan
• Adjunctive
• Dilatasi intra & extrahepatic ducts & inflammasi CBD.
• Keuntungan :
• Patologi lain : Complications : ampullary tumors, pericholecystic fluid and liver abscesses right-sided diverticulitis, papillary necrosis,
• Kerugian :
• Gallstones tak jelas
• “unstable patients” berbahaya.
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Pemeriksaan Pencitraan : Pemeriksaan Pencitraan : MRI CholangiografiMRI Cholangiografi
Sensitivitas : 91.6 %, Spesifisitas : 100 %, Akurasi : 96.8 %
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Pemeriksaan Pencitraan: ERCPPemeriksaan Pencitraan: ERCP
Sindroma Mirizzi & electrohydrauliclithrotripsy
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Diagnosis Banding :Diagnosis Banding :
• Kholesistitis akut , Sindroma Mirizzi• Abses hati piogenik• Pankreatitis akut• Hepatitis virus akut• Hepatitis alkoholik , sirrosis alkoholik• Kholestatis intrahepatik karena obat-
obatan, sirrosis bilier primer.
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Terapi Awal : MedikamentosaTerapi Awal : Medikamentosa
• 70-85% akan membaik• ABCs, IV, pulse oximetry, oxygen, ECG & monitoring (berat :
noninvasif). • NGT. • “ Volume resuscitation “ + “ parenteral antibiotics” (sambil
menungu diagnosis)• NPO. • Place a Foley catheter: monitor urine output.• Vitamin K, Analgetik• Observasi ketat : menentukan kebutuhan dekompresi
emergency dalam 48 - 72 jam, 15% tak membaik : surgical / endoscopic decompression
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Jenis antibiotika :Jenis antibiotika :
• Broad spectrum antibiotics:– Penicillin broad spektrum– Aminoglikosida + penicillin– Cephalosporin generasi III + Metroniodazole– Imipenem + Cilastatin– Pefloxacin
• Profilaksis : Cephalosporin generasi II• Penicillin broad spectrum
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Terapi Bedah Emergensi : Terapi Bedah Emergensi : DekompresiDekompresi
• Dilakukan drainase dengan cara :– Cholecystostomy/Choledochostomy
• Open : anestasi lokal( mortalitas 40%)• USG Guided Percutaneus
– PTC– ERCP + Sphincterotomy : pembersihan
batu,pus (mortalitas 0,42%, complication rate 6 %)
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Terapi Bedah Definitif :Terapi Bedah Definitif :
• Tergantung jenis patologi, etiologi, letak sumbatan, dapat :– Kholesistektomi– CBDE + T-tube– Sphincteroplasty (stenosis)– Anastomosis bilioenterik :
kholedochoduodenostomi, kholedochojejunostomy, hepatico jejunostomy
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Algoritma Cholangitis dengan Algoritma Cholangitis dengan penyebab batu empedupenyebab batu empedu
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Pengelolaan Cholelithiasis:Pengelolaan Cholelithiasis:
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One VS Two Step Approach :One VS Two Step Approach :
• LC +LTCDCBDE :
• Keuntungan– Biaya murah– Lama rawat
singkat– Morbiditas rendah
• LC + pre/post op/ ERS:
• Keuntungan :– Waktu operasi
singkat– Tidak memerlukan
teknik yang tinggi– Alat-alat lebih
sedikit
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One VS Two Step Approach :One VS Two Step Approach :
• Kerugian :– Teknik lebih sulit– Biaya alat mahal– Waktu operasi
lama– Biaya kamar
operasi meningkat
• Kerugian :– Perawatan di RS
lebih lama– Biaya keseluruhan
meningkat– Morbiditas dapat
meningkat– Dua prosedur yang
terpisah
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Pengelolaan CholedocholitihiasisPengelolaan Choledocholitihiasis
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Pengelolaan Choledocholithiasis:Pengelolaan Choledocholithiasis:
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Terapi Bedah :Terapi Bedah :
• Transcystic CBDE• Fluoroscopic Wire Basket Retrieval• Ampullary baloon dilatation• Laparoscopic Choledochotomy• Antegrade Transcystic Sphincterotomy• Open CBDE
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Terapi Bedah : Laparoskopi Terapi Bedah : Laparoskopi Cholecystektomi + CholangiografiCholecystektomi + Cholangiografi
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Terapi Bedah : Terapi Bedah : Eksplorasi CBD per laparoskopiEksplorasi CBD per laparoskopi
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Terapi Non operatif :Terapi Non operatif :
• ERCP
• Percutaneus Transhepatic Stone Removal
• Observasi
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ERCP :ERCP :
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Percutaneus Transhepatic Percutaneus Transhepatic Stone RemovalStone Removal
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Prognosis :Prognosis :Faktor yang meningkatkan mortalitasFaktor yang meningkatkan mortalitas
• Umur• Febris• Lekositosis• Syok Septik• Kultur darah (+)• Gangguan sistem
phagositosis
• Immunosuppresi• Adanya Neoplasma
hepar• Obstruksi
intrahepatal multipel• Penyakit hepar
kronis• Abses hepar
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Terima KasihTerima Kasih