1. Cholangitis & Management of Choledocholithiasis
Ruby Wang MS 3
Surg 300A
8/20/07

2. Content Case Cholangitis Clinical manifestations Diagnosis Treatment
Diagnosis and management of choledocholithiasis
Pre-operative
Intra-operative
Post-operative

3. Case
HPI:
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.
ROS: negative otherwise
PE:
VS: T 36.2, P98 , RR 18, BP 124/64
Abdominal exam significant for RUQ TTP
Labs
AST 553, ALT Alk Phos Bilirubin 2.7
WBC 30.3
Imaging
Abdominal US: multiple gallstones, no pericholecystic fluid, no extrahepatic/intrahepatic/CBD dilatation

4. 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
Choledocholithiasis
Obstructive tumors
Pancreatic cancer
Cholangiocarcinoma
Ampullary cancer
Porta hepatis
Others
Strictures/stenosis
ERCP
Sclerosing cholangitis
AIDS
Ascaris lumbricoides

5. Epidemiology Nationality Sex Age
U.S: uncommon, and occurs in association with biliary obstruction and causes of bactibilia (s/p ERCP)
Internationally:
Oriental cholangiohepatitis endemic in SE Asia- recurrent pyogenic cholangitis with intrahepatic/extrahepatic stones in 70-80%
Gallstones highest in N European descent, Hispanic populations, Native Americans
Intestinal parasites common in Asia
Sex
Gallstones more common in women
M: F ratio equal in cholangitis
Age
Median age between 50-60
Elderly patients more likely to progress from asymptomatic gallstones to cholangitis without colic

6. Pathogenesis
Normally, bile is sterile due to constant flush, bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duodenal reflux and ascending infection
ERCP or biliary stent insertion can disrupt the Sphincter of Oddi barrier mechanism, causing pathogeneic bacteria to enter the sterile biliary system.
Obstruction from stone or tumor increases intrabiliary pressure
High pressure diminishes host antibacterial defense- IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization.
Bacteria gain access to biliary tree by retrograde ascent
Biliary obstruction (stone or stricture) causes bactibilia
E Coli (25-50%)
Klebsiella (15-20%),
Enterobacter (5-10%)
High pressure pushes infection into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%).
Adam.about.com
Gpnotebook.co.uk Pathology.med.edu

7. Clinical Manifestations
RUQ pain (65%)
Fever (90%)
May be absent in elderly patients
Jaundice (60%)
Hypotension (30%)
Altered mental status (10%)
Charcot’s Triad:
Found in 50-70% of patients
Reynold’s Pentad:
Additional History
Pruitus, acholic stools
PMH for gallstones, CBD stones,
Recent ERCP, cholangiogram
Additional Physical
Tachycardia
Mild hepatomegaly

8. Diagnosis: lab values CBC Metabolic panel Amylase/Lipase
79% of patients have WBC > 10,000, with mean of 13,600
Septic patients may be neutropenic
Metabolic panel
Low calcium if pancreatitis
88-100% have hyperbilirubinemia
78% have increased alkaline phosphatase
AST and ALT are mildly elevated
Aminotransferase can reach 1000U/L- microabscess formation in the liver
GGT most sensitive marker of choledocholithiasis
Amylase/Lipase
Involvement of lower CBD may cause 3-4x elevated amylase
Blood cultures
20-30% of blood cultures are positive

9. Diagnosis: first-line imaging
Ultrasonography
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
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
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
Disadvantages
Sensitivity to contrast
Poor imaging of gallstones
Med.virgina.edu
Soto et al. J. Roenterology. 2000

10. Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
Advantage
Detects choledocholithiasis, neoplasms, strictures, biliary dilations
Sensitivity of %, specificity of % of choledocholithiasis
Minimally invasive- avoid invasive procedure in 50% of patients
Disadvantage:
cannot sample bile, test cytology, remove stone
Contraindications: pacemaker, implants, prosthetic valves
Indications
If cholangitis not severe, and risk of ERCP high, MRCP useful
If Charcot’s triad present, therapeutic ERCP with drainage should not be delayed.
Endoscopic retrograde cholangiopancreatography (ERCP)
Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction
Therapeutic option when CBD stone identified
Stone retrieval and sphincterotomy
Disadvantage
Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding
Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

11. Medical Treatment Resucitate, Monitor, Stabilize if patient unstable
Consider cholangitis in all patients with sepsis
Antibiotics
Empiric broad-spectrum Abx after blood cultures drawn
Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)
Carbapenems: gram negative, enterococcus, anaerobes
Levofloxacin ( mgIV qD) for impaired renal fxn.
- 80% of patients can be managed conservatively hrs Abx
- If fail medical therapy, mortality rate 100% without surgical decompression: ERCP or open
- Indication: persistent pain, hypotension, fever, mental confusion

12. Surgical treatment Endoscopic biliary drainage
Endoscopic sphincterotomy with stone extraction and stent insertion
CBD stones removed in 90-95% of cases
Therapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression
Surgery
Emergency surgery replaced by non-operative biliary drainage
Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal
Elective surgery: low M & M compared with emergency survey
If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

13. Our case… Condition: ERCP attempted
No acute distress, reasonably soft abdomen
ERCP attempted
Duct unable to cannulate due to presence of duodenum diverticulum at site of ampulla of Vater
Laparoscopic cholecystectomy planned
Dissection of triangle of Calot
Cystic duct and artery visualized and dissected
Cystic duct ductotomy
Insertion of cholangiogram catheter advanced and contrast bolused into cystic duct for IOC
Intraoperative cholangiogram
Several common duct filling defects consistent with stones
Decision to proceed with CBD exploration

14. 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
Intra-op
Post-op
We know that she has elevated LFTs.

15. Pre-op diagnosis & management
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
Treatment:
ERCP
Surgery

16. Intra-op diagnosis and management
Diagnosis: intraoperative cholangiography (IOC)
Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects.
Detect CBD stones
Potentially identify bile duct abnormalities, including iatrogenic injuries
Sensitivity 98%, specificity 94%
Morbidity and mortality low
Treatment
Open CBD exploration
Most surgeons prefer less invasive techniques
Laparoscopic CBD exploration
via choledochotomy: CBD dilatation > 6mm
via cystic duct ( %)
CBD clearance rate 97%
Morbidity rate 9.5%
Stones impacted at Sphincter of Oddi most difficult to extract
Intraoperative ERCP

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

18. Open surgery vs Endoscopic sphincterotomy
In patients with intact gallbladders, ES or open choledochotomy?
Design: 237 patients with CBD stone and intact gallbladders, 66% managed with ES and rest with open choledochotomy
Results: No significant difference in morbidity and mortality rates
Lower incidence of retained stones after open choledochotomy
Conclusion: open surgery superior to ES in those with intact gallbladders
Miller et al. Ann Surg 1988; 207:
Is ES followed by open CCY superior to open CCY+ CBDE?
Results: Initial stone clearance higher with open surgery (88% vs 65%, p< 0.05)
Conclusion: routine preoperative ES not indicated
Stain et al. Ann Surg 1991; 213:
Cochraine database of systematic reviews
Design: 8 trials randomized 760 patients comparing ERCP with open surgical clearance
Results: Open surgery more successful in CBD stone clearance, associated with lower mortality
Conclusion: open bile duct surgery superior to ES
Cochrane database of systematic reviews 2007
In patients with severe cholangitis, open or ES?
Study design: Randomized, prospsective trial of 82 patients with choledocholithiasis and severe toxic cholangitis managed endoscopically or with open choledochotomy
Results: In group managed initially with endoscopic drainage, need for ventilatory support (29% vs 63%) and mortality (33% vs 66%) significantly less
Conclusion: toxic cholangitis should managed with endoscopic sphincterotomy
Lai et al. J Engl J Med 1992; 326:

19. Laparoscopic CBD Exploration
In 1989, laparoscopic removal of gallbladder replaced open surgery
In the past decade, laparoscopic CBD exploration (LCBDE) developed
Techniques
IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones
Choledochotomy
If cystic duct < CBD stone, If CBD > 6mm
If stone located proximal to cystic duct-common bile duct junction
If stone impacted in bile duct or papilla
Transcystic approach
If CBD < 6mm in diameter
Cystic duct dissected close to junction with CBD, transverse incision made
Guidewire into CBd through cholangiogram catheter under fluoroscopy
Osotonic NaCl irrigate CBD to flush small stones through sphincter of Oddi
Unsuccessful in 10-20% of patients
Contraindications: pancreatitis, sphincter anomalies,
Results
High rate of lap CBD clearance: %
Similar success rates between transcystic and choledochotomy
Conversion to open %
Causes : multiple/impacted stones, bleeding, unclear anatomy,equipment failure
Length of hospital stay shorter in LCBDE than ES
Mortality and Morbidity
No difference between LCBDE and ES
Cochrane database of systematic reviews 2007

20. Post-op Diagnosis and Management
T-tube cholangiography
T-tube placed following CBDE to diagnosis and manage retained stones
Retained CBD stones in 2-10% of patients after CBD exploration
If not obstruction, tube is clamped and left for 6 weeks.
Cholangiogram repeat after 6 wks
ERCP
Treatment of retained stones undetected or left behind

21. In summary Non-surgical care first line
Goal: extract stone, but if not possible, drain bile to improve condition until definitive surgical intervention
ERCP: both diagnostic and therapeutic
Stones> 1cm - Sphincterotomy needed before extraction
Stones > 2cm: require lithotripsy or chemical dissolution
PTC
Surgical Care if endoscopy and IR drainage fail
Issues
Exploration of CBD
Fate of gallbladder
CBD exploration: laparoscopy first line
Transcystic:
Choledochotomy
CBD exploration: open
If laparoscopy has failed or contraindicated
T-tube cholangiogram days posto
Open CBD is safe option, but limited to setting of concomitant open surgery

22. …our case Open procedure Cholecystectomy CBD exploration
Due to previous failure of ERCP due to duodenum diverticulum
Incision joining epigastric port with subcostal inciion
Dis
Cholecystectomy
Gallbladder was dissected free from liver bed
Cystic artery/duct identified, ligated.
CBD exploration
2 suture splaced in direction of common duct through anterior wall in the same longitudinal direction
Choledochotomy- extended in both proximal and distal directions of CBD
4 CBD stones evacuated
Catheter advanced within CBD to perform sphincterotomy
T-tube placed within common bile duct.