1. Murad Aljiffry MD FRCSC
Biliary Emergencies
Murad Aljiffry MD FRCSC

2. 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

3. 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?

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

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

6. 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

7. 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

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

9. 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

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

11. 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

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

13. 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

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

15. 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

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

19. 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

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

21. 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%

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

24. 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

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

27. 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

28. 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

29. 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

30. Questions?

31. 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

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

33. Case 2
H/O gastric bypass
2:00 am

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

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

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

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

38. 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)

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

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

42. Biliary Drainage
Endoscopic
Surgical
Percutaneous

43. 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

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

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

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

50. Questions?