Management of Acute Cholangitis - Department of Surgery …€¦ · · 2012-10-31Case Presentation ... -Acute cholangitis is a direct result of ascending bacterial infection,
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Management of Acute Cholangitis Marilyn Ng, MD Dept. of Surgery M&M Conference Downstate Medical Center Oct 25, 2012 www.downstatesurgery.org
Today I will be sharing with you the management of gallstone-induced acute cholangitis
Case Presentation
94 yo woman w/ choledocholithiasis
with 1 day hx of RUQ abd pain
Fevers, chills, nausea & vomiting
PMHx: HTN, DM, colon cancer
SHx: left hemicolectomy
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On Physical Exam
Vitals: Tm 103 F BP 165/71 HR 93
Skin: Midline abd scar
Abd: soft, ND, RUQ tenderness,
(+) Murphy’s sign, no hernias
Back: no CVAT
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CT www.downstatesurgery.org
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Presentation Notes
CT scan Minimal intrahepatic biliary ductal dilatation with CBD dilatation to 1.5 cm and choledocholithiasis Cholelithiasis with gallbladder wall thickening and edema c/w acute cholecystitis
CT www.downstatesurgery.org
CT www.downstatesurgery.org
CT www.downstatesurgery.org
MRCP www.downstatesurgery.org
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Her CT scan was compared to a MRCP performed 2 weeks prior to admission that demonstrated -Distal choledocholithiasis with CBD dilatation up to 1.2 cm (on 4/30/12) with no evidence of choledocholithiasis
Labs
CBC: 20.5>13.7/45<224
BMP: 135/4.6/105/22/15/1<226
LFT: 6/2.7/121/135/271/2.0 A 43 L 91
U/A: normal
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Hospital Course
Choledocholithiasis, acute
cholecystisis & ascending cholangitis
IV resuscitation and IV antibiotics
Failed ERCP and PTC
IR performed temporizing
percutaneous cholecystostomy
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Presenter
Presentation Notes
-Vanco/zosyn -mildly dilated intrahepatic biliary system on CT with IV contrast -after failed attempt of ERCP and unlikely access via PTC, IR performed a percuatneous cholcystostomy as a temporizing measure in a setting of concurrent acute cholecystitis
Open Cholecystectomy
Cholecystostomy tube removed
Cholecystectomy
CBD exploration & T-tube placement
Jackson – Pratt drain
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Presentation Notes
-On HD#2, after aggressive IVF resuscitation she was hemodynamically stable and was taken to the OR for …
Post – Op Course
POD#2: Extubated
POD#3: Transferred to floor
POD#4: Tolerated regular diet
POD#7: Normal T-tube cholangiogram
POD#8: Discharged to home
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Acute Cholangitis
Acute ascending cholangitis (AAC)
History of AAC management
Management options
Conclusion
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History of Cholangitis
1877 – Dr. Jean-Martin Charcot recognized triad of symptoms
1958 – Dr. Benedict Reynolds recognized a more severe form
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Presenter
Presentation Notes
-In 1877, Charcot first described “hepatic fever” as a triad of symptoms, what we now know as Charcot’s triad (RUQ abd pain, fever, jaundice) -Later Dr. Reynolds described a more sever form of cholangitis, which included AMS and hypotension (sepsis)
U.S. Epidemiology
20 million U.S. adults have gallstones
Cholangitis relatively uncommon
Choledocholithiasis primary etiology
1-3% after biliary instrumentation
Median age 50 – 60 years
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Other causes: Benign conditions Choledocholithiasis Primary Secondary Pancreatitis (chronic/acute), including pancreatic pseudocyst Papillary stenosis Mirizzi syndrome Choledochal cysts (type V, Caroli disease) Primary sclerosing cholangitis Malignancies Pancreatic cancer Cholangiocarcinoma Porta hepatis tumor/metastasis Iatrogenic Obstructed biliary endoprosthesis Iatrogenic biliary stricture Direct surgical trauma Ischemia-induced stricture Anastomotic stricture (biliobiliary/bilioenteric anastomosis)
AAC Pathophysiology Ascending bacterial infection E. coli, Klebsiella, Enterobacter
Biliary obstruction and stasis Intact sphincter of Oddi
Unimpeded efflux of bile from CBD
Immunoglobulin A & bile salts
Instrumentation & foreign body
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Presentation Notes
-Acute cholangitis is a direct result of ascending bacterial infection, usually due to E. coli, Klebsiella and/or Enterobacter -This occurs when the defense systems that protect bile sterility are compromized that lead to biliary obstruction and stasis. -These mechanisms: Intact sphincter of Oddi Unimpeded efflux of bile from CBD Immunoglobulin A and bile salts -Another common cause is due to instrumentation and placement of foreign body (stent)
Diagnostic Criteria
Do NOT delay management !
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The diagnostic criteria for acute cholangitis was developed from a multicenter study in Tokyo and is referred to as the Tokyo Guidelines fro Acute Cholangitis 2013. -Suspected diagnosis: one item in A + one item in either B or C -Definite diagnosis: one item in A, one item in B and one item in C Do not delay management to meet Tokyo guideline diagnostic criteria. Rather, treat expeditiously if clinical suspicion is present
Comparison www.downstatesurgery.org
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The most recent TG (2013) was re-evaluated to improve diagnostic sensitivity of acute cholangitis. In this iteration, was able to do so with the removal of abdominal pain as a diagnostic factor. -While Charcot’s triad is highly specific, it has poor sensitivity. -TG13 was able to improv sensitivity to 92% and specificity of 78% -Reynold’s pentad (5%) Jaundice (90%) Fever & abdominal pain (66%)
EUS findings of diffuse and/or concentric wall thickening of more than 1.5 mm and intraductal heterogenous echgenicity without acoustic shadowing are highly accurate and predictive for diagnosing cholangitis
Management
15 – 20% non-responsive to conservative therapy
Risk factors for suppurative AAC
Impacted stones
Active smoker
Age > 70 yrs
Gallbladder stones
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Independent risk factors for developing acute suppurative cholangitis in patients with CBD stones include impacted stones, active smoker status, age >70 years, and additional stones within the gallbladder.
Management
Resuscitation & correct coagulopathy
Antibiotics 1 – 2 weeks (85% respond)
Fluoroquinolones + Flagyl
PCN + B-lactam combination
Goal: Biliary decompression
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Severity www.downstatesurgery.org
Timing of Biliary Drainage www.downstatesurgery.org
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Presentation Notes
In a descriptive analysis of patients undergoing biliary drainage, a majority of drainage procedures are performed within the first 24 hrs regardless of the severity of cholangitis
Decompression Indications
Persistent abdominal pain
Hypotension despite resuscitation
Fever > 102 F
Mental confusion
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Biliary Drainage
Endoscopic
Percutaneous transhepatic
Surgical
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Various endoscopic treatment options are available from the placement of nasobiliary catheters or biliary stents to sphincterotomy and stone extraction. In patients who have responded to antibiotic therapy, sphincterotomy with bile duct clearance is preferred, whereas drainage catheters are used in those with ongoing sepsis and multiple large stones.117 In critically ill patients or in those with coagulopathy, concerns about bleeding and increased procedure times are associated with endoscopic sphincterotomy.
ERCP
Treatment of choice
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Presentation Notes
-Endoscopic sphincterotomy and/or stent insertion treatment of choice -90-95% of patients’ CBD stone removed successfully following sphincterotomy -Avoid septicemia by aspirating bile duct prior to contrast injection -Following endoscopic sphincterotomy, serious complications can occur and may require surgical intervention. These complications include hemorrhage, perforation, cholangitis, and pancreatitis. Complications occur in 5–6% following endoscopic sphincterotomy and death occurs in 1%. Approximately 75–80% of complications can be managed without surgery.
ERCP
Nasobiliary catheter if coagulopathic
Internal stent permits adequate drainage even without sphincterotomy
Lithotripsy for stones > 2 cm diameter
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On the other hand, in comparing nasobiliary catheters with biliary stents for the treatment of acute cholangitis, a randomized study found both to be equally effective, but stents were more comfortable and avoided the risk of accidental removal.115
PTC
Alternative when ERCP unavailable, unsuccessful or contraindicated
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-Percutaneous transhepatic drainage is reserved for patients in whom the papilla is inaccessible or ERCP has failed and for those suspected of hilar cholangiocarcinoma, hepatolithiasis, and intrasegmental cholangitis.115,117 Although successful in 90% of patients with biliary obstruction, percutaneous drainage has higher rates of morbidity (30–80%) and mortality (5–15%) than endoscopic techniques. As with ERCP, coagulopathy must be corrected prior to the procedure. -In comparison with percutaneous drainage, ERCP also has been shown to have lower morbidity, shorter hospitalization, and higher definitive success rates
Surgical Decompression Rarely performed
CBD exploration for difficult stones
Choledochotomy + T-tube for emergency Lower mortality rate
than CCY + CBD exploration
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Comparison of Drainage www.downstatesurgery.org
Presenter
Presentation Notes
Sugiyama and colleagues found that in elderly patients (age 80 or older) with acute cholangitis, endoscopic drainage had lower morbidity (16.7%) and mortality (5.6%) than surgical (87.5% and 25%, respectively) or percutaneous drainage (36.4% and 9.1%, respectively) In comparison with percutaneous drainage, ERCP also has been shown to have lower morbidity, shorter hospitalization, and higher definitive success rates
Summary
Result of biliary stasis & infection
80% respond to conservative therapy
ERCP first line drainage therapy
CBD stones removed in 90-95% after sphincterotomy
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True or false: Management of acute cholangitis should be delayed until Tokyo Guidelines 2013 diagnostic criteria is met.
TRUE FALSE
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What percentage of cholangitis patients fail conservative management (IV antibiotics)?
A. 100%
B. 75%
C. 50%
D. 20%
E. 1%
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After IVF resuscitation & IV antibiotics, which is the preferred first line treatment for acute cholangitis?
A. Watchful waiting
B. Laparoscopic cholecystectomy alone
C. ERCP with sphincterotomy or stenting
D. Percutaneous transhepatic cholecystostomy
E. CBD exploration
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References Fried GM et al. Cholecystectomy and common bile duct exploration.
ACS Surgery: Principles and Practice. BC Decker, Inc; 2009.
Hui CK et al. Does the addiotn of endoscopic sphincterotomy to stent insertion improve drainage of the bilde duct in acute suppurative cholangitis? Gastrointest Endosc 2003;58:500.
Jonnalagadda and Strasberg. Acute cholangitis. Current Surgical Therapy, 10th Ed, pp 713-720.
Kiriyama S et al. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci 2012;19:548–556
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References McFadden DW, Nigam A. Chapter 33. Choledocholithiasis and
