Murad Aljiffry MD FRCSC Biliary Emergencies Murad Aljiffry MD FRCSC

Case 1 61 year old male Abdominal pain for 5 days Associated with: Fever, malaise, chest pain with shortness of breath and anorexia Past Hx.: diverticulitis treated Physical examination HR 120, B/P 100/60 Localized RUQ peritoneal findings

Case 1 Lab: US: What next? WBC: 18, Hb: 10, Creat 130, T.bili 60, ALP 350, Alb 25 US: Hypoechoic liver lesion with thickened irregular wall Gall stones What next?

Case 1 Abdominal CT (contrast-enhanced) Hypodense lesion of left lobe(5.5cm) occupies segment II and III well demarcated, round

Liver Abscess Pyogenic(80%): E. coli, K.P Paracytic(10%): Entamaeba histolytica Others(10%): candida

Epidemiology Incidence in the US is 8-15 per 100,000 Male to female ratio is 2:1 in recent studies 5th-7th decades of life Risk factors : DM, underlying hepatobiliary or pancreatic malignancy, and liver transplant

Etiology Biliary disease accounts for 20-40% Extrahepatic obstruction leading to ascending cholangitis and abscess CBD stones Benign and malignant tumors Biliary enteric anastamoses or manipulation

Etiology Infection via portal system Infectious process originates in abdomen, reaches liver by embolization through portal system Appendicitis, diverticulitis, IBD, proctitis

Etiology Hematogenous via hepatic artery From systemic septicemia such as endocarditis and pyelonephritis Direct extension or trauma No cause (cryptogenic) in 20-40% of cases

Etiology Underlying etiology of 1086 cases of liver abscess compiled from the literature

Microbiology Most contain more than one organism Blood cultures positive in 33-65% E.Coli Klebsiella (is an important emerging infection associated with endophthalmitis ) Bacteroides Streptococcal (including S. aureus and S. pyogenes) Candida species : usually occurs in immunosuppressed patients

Microbiology Microbiologic results from 312 cases of liver abscess compiled from the literature

Clinical Fever (85-100%), abdominal pain (50-75%) About one-half of patients with liver abscess have hepatomegaly, RUQ tenderness, or jaundice Right shoulder pain, pleuritic chest pain Anorexia, weight loss, mental confusion

Diagnosis-Lab CBC: anemia in 50-80%, leukocytosis in 75-96% LFTs: elevated alkaline phosphatase 95-100%, elevated AST, ALT 40-60% Elevated bilirubin in 20-50% Decreased albumin in 71-87%

Diagnosis-Imaging CT and ultrasound are the modalities of choice (80-100% sensitive) An abscess appears radiologically as a fluid collection with surrounding edema and inflammation (rim enhancement) that may contain loculated subcollections and gas

Treatment Initiation of antibiotic therapy Diagnostic aspiration and drainage of abscess Surgical drainage in selected patients

Antibiotic Therapy Empiric broad-spectrum antibiotics (draw blood culture before) A third generation cephalosporin such as ceftriaxone + metronidazole Fluoroquinolone (eg, ciprofloxacin) + metronidazole Monotherapy with a carbapenem or an extended spectrum penicillin

Antibiotic Therapy Immunocompromised patients with multiple abscesses are best treated with high dose antibiotics rather than open or percutaneous drainage

Drainage For single abscesses with diameter ≤5 cm : percutaneous catheter drainage or needle aspiration is acceptable (usually multiple) For single abscesses with diameter >5 cm : Percutaneous management (catheter drainage no needle aspiration) Some favor surgical intervention over percutaneous drainage, treatment failure lower with surgical drainage Success 70-90%

Complications of Percutaneous Drainage Perforation of a viscous Pneumothorax Bleeding Leakage of pus into the abdomen

Surgical Therapy Indications of surgical drainage: Co-existing intra-abdominal disease that requires operative management Failure of percutaneous drainage Multiple abscesses Loculated abscesses Abscesses with viscous contents obstructing the drainage catheter Ascites or coagulopathy

Surgical Therapy Transthoracic, extraperitoneal, transperitoneal Transperitoneal is preferred as intra-abdominal pathology can be dealt with Laparoscopic or open

Duration of therapy Follow imaging, WBC count and serum CRP Drainage catheters should remain in place until drainage is minimal Patients should be treated for 2-4 weeks

Complications Result from rupture of abscess into adjacent organs or cavities Pleuropulmonary include effusions, empyema, bronch-hepatic fistula Intraabdominal include subphrenic abscess, rupture into peritoneal cavity, or any intraabdominal organ

Prognosis Mortality rate : 10- 20% If untreated fatal (100% mortality rate) Mortality appears to be related to underlying comorbidities rather than to the abscess itself Poor prognosis: age >70, multiple abscesses, polymicrobial infection, immunosupression, malignancy, and delay diagnosis

Questions?

Case 2 40 y.o. female presents to ER with 12 hr history of upper abdominal pain and fever Associated nausea and vomiting Lab: wbc 12, AST100, ALT220, GGT1400, ALP 1340, Tbili 75

Case 2 Amylase and Lipase slight elevation U/S – multiple small stones in gallbladder, CBD9mm, no intrahepatic dilatation What next?

Case 2 H/O gastric bypass 2:00 am

Acute Cholangitis Pus under pressure May be difficult to distinguish from acute cholecystitis Managed medically with support, antibiotics Drainage is key

Etiology Stone disease Anomalous PBJ Malignant biliary obstruction Primary sclerosing cholangitis Post instrumentation Cholangiography Surgery Sphincterotomy Stents

Microbiology 80% patients +ve biliary cultures (multiple organisms frequent ) E.Coli (commonest) Enterococci Klebsiella sp Proteus sp Pseudomonas sp Bacteroides sp

Clinical Presentation Charcot’s triad Pyrexia, Pain, Jaundice Elevated liver enzymes Leukocystosis

Diagnosis Clinical Ultrasound CT Duct dilation Presence of gallbladder or CBD stones CT R/O other causes MRCP (especially for hilar obstruction, if stable pt.) ERCP (generally for therapy)

Management Fluid resuscitation Triage (floor or ICU) Correction of coagulopathy and electrolytes Blood cultures Antibiotics (broad spectrum)

Management Most pt will respond and will require urgent biliary decompression 10-15% of patients fail to respond or deteriorate within 12-24 hours, thus require emergent biliary decompression

Biliary Drainage Endoscopic Surgical Percutaneous

Endoscopic Biliary Drainage Can be done at bedside in ICU with portable flouroscopy Superior to surgical drainage Mortality of endoscopic vs surgical drainage 10% vs 32% RCT (Lai NEJM 1992) Preferable to percutaneous drainage Morbidity less (Sugiyama Arch Surg 1997, AmJGastro 1998) Especially in presence of ascites, coagulopathy

Endoscopic Biliary Drainage Sphincterotomy Caution due to bleeding risk Stone removal Stent

Percutaneous Biliary drain When endoscopic drainage fails Inaccessible papilla Roux-en-Y Hepatolithiasis Segmental cholangitis (complex hilar tumor)

Surgical Biliary drain Last resort Decompression of biliary tree and placement of T tube

Questions?