acute cholangitis 1. etiology cholangitis may be acute or chronic symptoms result from...

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ACUTE CHOLANGITIS

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Etiology

Cholangitis may be acute or chronic

Symptoms result from inflammation, which usually requires at least partial obstruction to the flow of bile

Ascending cholangitis or acute cholangitis is a bacterial infection ascending from its junction with the duodenum superimposed on an obstruction of the biliary tree most commonly from a gallstone.

It may be associated with neoplasm or strictureHarrison’s Principles of Internal Medicine 17thedhttp://emedicine.medscape.com/article/774245-overview

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Etiology

Bile duct obstruction, which is usually present in acute cholangitis, is generally due to gallstones

10–30% of cases are due to other causes: benign stricturing (narrowing of the bile duct without

an underlying tumor) postoperative damage or an altered structure of the

bile ducts such as narrowing at the site of an anastomosis (surgical connection)

various tumors (cancer of the bile duct, gallbladder cancer, cancer of the ampulla of Vater, pancreatic cancer or cancer of the duodenum)

Kimura Y, Takada T, Kawarada Y et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg14 (1): 15–26

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Etiology

Choledocholithiasis was the most common cause of biliary tract obstruction resulting in cholangitis

Over the past 20 years, biliary tract manipulations/interventions and stents have reportedly become more common causes of cholangitis

Hepatobiliary malignancies are a less common cause of biliary tract obstruction and subsequent bile contamination

Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. Aug 4 2009;[Medline].

http://www.medscape.com/medline/abstract/19652653

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Etiology

Most common organisms isolated in bile Escherichia coli (27%) Klebsiella species (16%) Enterococcus species (15%) Streptococcus species (8%) Enterobacter species (7%) Pseudomonas aeruginosa (7%)

Organisms isolated from blood cultures are similar to those found in the bile E coli (59%), Klebsiella species (16%), Pseudomonas

aeruginosa (5%), and Enterococcus species (4%)

http://emedicine.medscape.com/article/774245-overview

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Pathogenesis

Main factors in the pathogenesis of acute cholangitis biliarytract obstruction elevated intraluminalpressure infection of bile

A biliary system that is colonized by bacteria but is unobstructed, typically does not result in cholangitis

Biliary obstruction diminishes host antibacterial defenses, causes immune dysfunction, and subsequently increases small bowel bacterial colonization

The infection can be suppurative in the biliary tract

In the presence of gallbladder or common duct stones (CBD), the incidence of bactibilia increases

http://emedicine.medscape.com/article/774245-overview

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Pathogenesis

http://emedicine.medscape.com/article/774245-overviewKinney TP (April 2007). "Management of ascending cholangitis". Gastrointest Endosc Clin N Am17 (2): 289–306

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Clinical Features

Cholangitis may present as anything from a mild, intermittent, and self-limited disease to a fulminant, potentially life-threatening septicemia

Symptoms result from inflammation, which usually is caused by at least partial obstruction to the flow of bile

On abdominal examination, the findings are indistinguishable from those of acute cholecystitis

Harrison's Principles of Internal Medicine 17th ed, Chapter 305Sabiston Textbook of Surgery, 18th ed.Schwartz's Surgery 2007

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Clinical Features

The most common presentation is fever with chills, right upper quadrant pain, and jaundice (Charcot's triad), present in about 2/3 of patients

The illness may progress rapidly with shock (hypotension, septicemia) and mental status changes, known as Reynolds pentad (e.g., fever, jaundice, right upper quadrant pain, septic shock, and disorientation/lethargy)


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Clinical Presentation

Fever and chills are the most common presentation and are due to cholangiovenous and cholangiolymphatic reflux

However, the presentation may be atypical, with little if any fever, jaundice, or pain (occurs most commonly in the elderly, who may have unremarkable symptoms until they collapse with septicemia)


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Diagnosis

Early diagnosis should be made based on clinical signs/symptoms and

laboratory findings.

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• Fever• Epigastric pain • Icteric sclerae• BP: 130/70• PR:105/min• RR:28/min• Slightly distended, tympanitic abdomen,

no mass• Hypoactive bowel sounds

Charcot’s Triad

Clinical Diagnosis of Acute Cholangitis

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Diagnosis: Laboratory Work-upThe diagnosis of acute cholangitis requires: WBC count - leukocytosis C-reactive protein level Liver function tests – hyperbilirubinemia, elevated ALT and AST

Assessment of the severity of the illness requires knowledge of the:

Platelet count Blood urea nitrogen Creatinine Prothrombin time (PT) Blood cultures (severity assessment and for selection of

antimicrobial drugs)

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Diagnosis: Imaging Studies

The role of diagnostic imaging in acute cholangitis is:

To determine the presence/absence of biliary obstruction

The level of the obstruction The cause of the obstruction, such as

gallstones and/or biliary strictures

Miura et al. 2007. Flowchart for the diagnosis and treatment of acute cholangitis and cholecystits. Journal of Hepatobiliary and Pancreatic Surgery. 14:27-34.

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Imaging Studies

Ultrasonography – first-line imaging modality Abdominal CT – first-line imaging modality Endoscopic Retrograde Cholangiography

(ERC) Percutaneous Transhepatic

Cholangiography (PTC)

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Imaging Studies

Ultrasonography Abdominal CT Endoscopic Retrograde Cholangiography



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Ultrasonography

Transabdominal ultrasonography is the initial imaging study of choice.

Performed in all patients suspected of having acute biliary inflammation / infection.

Ultrasonography can differentiate intrahepatic obstruction from extrahepatic obstruction and image dilated ducts.

In one study of cholangitis, only 13% of CBD stones were observed on ultrasonography, but dilated CBD was found in 64%.

A normal sonogram does not rule out acute cholangitis.

Schwartz’s Priciples of Surgery, 8th ed.Rosh AJ. 2008. Cholangitis: Differential Diagnoses and Workup. http://emedicine.medscape.com/article/774245-diagnosis

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Ultrasonography

Rosh AJ. 2008. Cholangitis: Differential Diagnoses and Workup. http://emedicine.medscape.com/article/774245-diagnosis

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Imaging Studies




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Abdominal CT

CT is adjunctive to and may replace ultrasonography. Spiral or helical CT improves imaging of the biliary

tree. CT cholangiography uses a contrast agent that is

taken up by the hepatocytes and secreted into the biliary system. Enhances the ability to visualize radiolucent stones and

increases detection of other biliary pathology. Dilated intrahepatic and extrahepatic ducts and

inflammation of the biliary tree are imaged. Gallstones are poorly visualized with traditional CT

scan.


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Abdominal CT


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Imaging Studies

Ultrasonography Abdominal CT Endoscopic Retrograde

Cholangiopancreatography (ERCP) Percutaneous Transhepatic


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Endoscopic Retrograde Cholangiopancreatography (ERCP)

The definitive diagnostic test (criterion standard for imaging the biliary system)

Diagnostic and therapeutic Patients with a high clinical suspicion for

cholangitis should proceed directly to ERCP. Shows the level and the reason for the

obstruction Allows culture of the bile Possibly allows the removal of stones if present Drainage of the bile ducts with drainage

catheters or stents.Schwartz’s Priciples of Surgery, 8th ed.Sabiston Textbook of Surgery, 18th ed.Rosh AJ. 2008. Cholangitis: Differential Diagnoses and Workup. http://emedicine.medscape.com/article/774245-diagnosis

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Imaging Studies




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Percutaneous Transhepatic Cholangiography (PTC)

Done if ERCP is not available Shows the level and the reason for the

obstruction Allows culture of the bile Possibly allows the removal of stones if

present Drainage of the bile ducts with drainage

catheters or stents.

Schwartz’s Priciples of Surgery, 8th ed.Sabiston Textbook of Surgery, 18th ed.Rosh AJ. 2008. Cholangitis: Differential Diagnoses and Workup. http://emedicine.medscape.com/article/774245-diagnosis

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Course of Acute Cholangitis

An ascending bacterial infection in association with partial or complete obstruction of the bile ducts

Hepatic bile is sterile, and bile in the bile ducts is kept sterile by continuous bile flow and by the presence of antibacterial substances in bile such as immunoglobulin.

Mechanical hindrance to bile flow facilitates bacterial contamination

Harrison’s Principle of Internal Medicine , 17th edition 2008

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May range from an acute ascending cholangitis, associated with incomplete bile duct obstruction, and ascending bacteria from the duodenum to acute obstructive suppurative cholangitis

Current diagnosis & treatment in infectious diseasesBy Walter R. Wilson, Merle A. Sande, William Lawrence Drew

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Non-suppurative Most common and may respond relatively

rapidly to supportive measures and to treatment of antibiotics

Suppurative The presence of pus under pressure in a

completely obstructed ductal system leads to symptoms of severe toxicity- mental confusion, bacteremia and septic shock

Harrison’s Principle of Internal Medicine 17th edition 2008

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Management

1. Antibiotics and supportive treatment2. Identify the severity of ascending

cholangitis 3. Urgent biliary decompression in some

cases ERCP with endoscopic sphincterotomy percutaneous transhepatic route Emergent operation and decompression of

the common bile duct with a T tube

Townsend: Sabiston Textbook of Surgery, 18th ed.

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Severity Assessment

Based on the response to treatment Mild (grade I) acute cholangitis Moderate (grade II) acute cholangitis Severe (grade III) acute cholangitis

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelineshttp://www.springerlink.com/content/j086279743640824/fulltext.pdf

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Mild (grade I) acute cholangitis

Medical treatment may be sufficient.


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Moderate (grade II) acute cholangitis

Patients with acute cholangitis who do not respond to medical treatment

early endoscopic or percutaneous drainage or even emergent operative drainage with a T-tube should be performed

A definitive procedure should be performed to remove the cause of the obstruction once the patient is in a stable condition


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Severe (grade III) acute cholangitis

Patients with acute cholangitis and organ failure Require organ support, such as ventilatory/

circulatory management, and treatment for disseminated intravascular coagulation (DIC) in addition to the general medical management

Urgent biliary drainage must be anticipated When the patient is stabilized, urgent (ASAP)

endoscopic or percutaneous transhepatic biliary drainage or an emergent operation with decompression of the bile duct with a T-tube should be performed.

Definitive treatment of the cause of the obstruction should be considered once the acute illness has resolved.


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Diagnosis of acute cholangitis

Launch of medical treatment

Severity assessment

Mild(Grade I)

Moderate(Grade II)

Severe(Grade III)

Observation

Earlybiliary

drainage

Urgentbiliary

drainage

Treatment for etiology (Endoscopic treatment, percutaneous treatment, or

surgery)


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Antibiotics and supportive treatment

Because of the wide range of possible infecting organisms and the possibility of mixed infection, broad-spectrum antibiotic is required, which should be able to cover gram-negative bacilli. Ampicillin together with an aminoglycoside Mezlocillin alone was found more effective and has fewer adverse effects but is

ineffective against Pseudomonas Trials comparing various antibiotics have not shown the superiority of any agent A reasonable choice for initial antibiotic treatment of acute cholangitis is ticarcillin

and clavulanante (Timentin) or piperacillin and tazobactam (Tazocin).

About 90% of patients with acute cholangitis respond to antibiotics and other supportive treatment within 24 to 48 hours

Response is usually measured by improvement of clinical signs and body temperature, normalizing liver function tests, and subjective improvement.

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=surg&part=A2741

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Surgical drainage

Stone extraction, T-tube insertion, transhepatic intubation of bile duct or bilio-enteric bypass

Has been associated with high morbidity and mortality

Age, comorbidities, jaundice, renal failure, acidosis, thrombocytopenia and malignant diseases are risk factors associated with increased perioperative mortality.


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Endoscopic drainage

Endoscopic management of bacterial cholangitis is as effective as surgical intervention.

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is safe and the preferred initial procedure for both establishing a definitive diagnosis and providing effective therapy.

Harrison‘s Principles of Internal Medicine 17th ed.

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Percutaneous transhepatic biliary drainage (PTBD)

Primary aim of emergency PTBD is to establish drainage rather than definitive cholangiography in the acute phase of cholangitis

Major advantage of PTBD compared with surgery or endoscopic treatment no need for systemic sedation or anesthesia, which can result in

hemodynamic instability and respiratory complications Disadvantage of PTBD includes

the need to puncture the liver which may result in serious complications, especially in patients with severe sepsis, clotting derangement and thrombocytopenia.

Higher complication rate and an inferior successful rate when compared with endoscopic drainage procedure

PTBD is reserved for patients who have strong contraindication for endoscopic intervention (for example, previous Billroth II gastrectomy) and who have failed endoscopic intervention or hilar cholangiocarcinoma.


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Management

Definitive operative therapy should be deferred until the cholangitis has been treated, the patient stabilized, and the

diagnosis confirmed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

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References

Fumihiko M. “Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines”. J Hepatobiliary Pancreat Surg (2007) 14:27–34. http://www.springerlink.com/content/j086279743640824/fulltext.pdf

Chi-Leung Liu & Sheung-Tat Fan. “Acute cholangitis”. Copyright © 2001 W. Zuckschwerdt Verlag GmbH. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=surg&part=A2741

Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. Aug 4 2009;[Medline].

Kimura Y, Takada T, Kawarada Y et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg14 (1): 15–26

Miura et al. 2007. Flowchart for the diagnosis and treatment of acute cholangitis and cholecystits. Journal of Hepatobiliary and Pancreatic Surgery. 14:27-34.


http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=surg&part=A2741 http://emedicine.medscape.com/article/774245-overview Harrison's Principles of Internal Medicine 17th ed. Sabiston Textbook of Surgery, 18th ed. Schwartz's Surgery 2007 Current diagnosis & treatment in infectious diseases by Walter R. Wilson, Merle A. Sande,

William Lawrence Drew

acute cholangitis 1. etiology cholangitis may be acute or chronic symptoms result from...

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