Transcript Cholangitis & CBD Stone Exploration

Cholangitis &
Management of
Choledocholithiasis
Ruby Wang MS 3
Surg 300A
8/20/07
Content
 Case
 Cholangitis
 Clinical manifestations
 Diagnosis
 Treatment
 Diagnosis and management of choledocholithiasis
 Pre-operative
 Intra-operative
 Post-operative
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 418. Alk Phos 466. Bilirubin 2.7
 WBC 30.3
 Imaging
 Abdominal US: multiple gallstones, no pericholecystic fluid,
no extrahepatic/intrahepatic/CBD dilatation
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
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Pancreatic cancer
Cholangiocarcinoma
Ampullary cancer
Porta hepatis
 Others
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Strictures/stenosis
ERCP
Sclerosing cholangitis
AIDS
Ascaris lumbricoides
Epidemiology
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Nationality
 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
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Sex
 Gallstones more common in
women
 M: F ratio equal in
cholangitis
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Age
 Median age between 50-60
 Elderly patients more likely
to progress from
asymptomatic gallstones to
cholangitis without colic
Pathogenesis
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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
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ERCP or biliary stent insertion can disrupt the
Sphincter of Oddi barrier mechanism, causing
pathogeneic bacteria to enter the sterile biliary system.
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Obstruction from stone or tumor increases intrabiliary
pressure
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High pressure diminishes host antibacterial defenseIgA production, bile flow- causing immune dysfunction,
increasing small bowel bacterial colonization.
Adam.about.com
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Bacteria gain access to biliary tree by retrograde
ascent
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Biliary obstruction (stone or stricture) causes bactibilia
 E Coli (25-50%)
 Klebsiella (15-20%),
 Enterobacter (5-10%)
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High pressure pushes infection into biliary canaliculi,
hepatic vein, and perihepatic lymphatics, favoring
migration into systemic circulation- bacteremia (2040%).
Gpnotebook.co.uk
Pathology.med.edu
Clinical Manifestations
 RUQ pain (65%)
 Fever (90%)
 May be absent in elderly patients
 Jaundice (60%)
 Hypotension (30%)
 Altered mental status (10%)
Additional History
Pruitus, acholic stools
PMH for gallstones, CBD stones,
Recent ERCP, cholangiogram
Additional Physical
Tachycardia
Mild hepatomegaly
Charcot’s
Triad:
Found in
50-70%
of
patients
Reynold’s
Pentad:
Diagnosis: lab values
 CBC
 79% of patients have WBC > 10,000, with mean of 13,600
 Septic patients may be neutropenic
 Metabolic panel
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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
Diagnosis: first-line imaging
Ultrasonography
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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
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CT
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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
Soto et al. J. Roenterology. 2000
Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
 Advantage
 Detects choledocholithiasis, neoplasms, strictures, biliary
dilations
 Sensitivity of 81-100%, specificity of 92-100% 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
 Advantage
 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%
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 (250-500mgIV qD) for impaired renal fxn.
- 80% of patients can be managed conservatively 12-24 hrs Abx
- If fail medical therapy, mortality rate 100% without surgical
decompression: ERCP or open
- Indication: persistent pain, hypotension, fever, mental confusion
Surgical treatment
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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
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Surgery
 Emergency surgery replaced by nonoperative 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
Our case…
 Condition:
 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
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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
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
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
Intra-op diagnosis and management
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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
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Treatment
 Open CBD exploration
 Most surgeons prefer less invasive techniques
 Laparoscopic CBD exploration
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via choledochotomy: CBD dilatation > 6mm
via cystic duct (66-82.5%)
CBD clearance rate 97%
Morbidity rate 9.5%
Stones impacted at Sphincter of Oddi most difficult to extract
 Intraoperative ERCP
Early years: Open CBD exploration &
Introduction of endoscopic sphincterotomy
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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
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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
Open surgery vs Endoscopic sphincterotomy
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In patients with intact gallbladders, ES or open choledochotomy?
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Is ES followed by open CCY superior to open CCY+ CBDE?
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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: 627-34
Cochraine database of systematic reviews
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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: 135-41
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?
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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: 1582-6
Laparoscopic CBD Exploration
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In 1989, laparoscopic removal of gallbladder replaced open surgery
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In the past decade, laparoscopic CBD exploration (LCBDE) developed
Techniques
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IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones
Choledochotomy
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Transcystic approach
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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
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
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High rate of lap CBD clearance: 73-100%
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Conversion to open 5.2-19.6%
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Similar success rates between transcystic and choledochotomy
Causes : multiple/impacted stones, bleeding, unclear anatomy,equipment failure
Length of hospital stay shorter in LCBDE than ES
Mortality and Morbidity
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No difference between LCBDE and ES
Cochrane database of systematic reviews 2007
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
In summary
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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 10-14 days posto
 Open CBD is safe option, but limited to setting of concomitant open surgery
…our case
 Open procedure
 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.