Cholangitis
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Acute cholangitis is an infection of the bile ducts caused by obstruction and bacterial overgrowth. It presents with fever, jaundice, and right upper quadrant pain (Charcot's triad). Obstruction leads to increased pressure and bacterial growth in the bile ducts. Diagnosis involves blood tests, imaging like ultrasound or CT, and testing bile if drained. Treatment is antibiotics, hydration, and relieving obstruction endoscopically or surgically. Antibiotics are continued until obstruction is fully resolved to prevent recurrence.
Cholangitis
- 1. Acute Cholangitis Dr. Lala Robin PG Resident, General surgery, CMC Ludhiana
- 2. Overview Definition Causes Pathophysiology and Effects of Biliary Obstruction Investigations Management
- 3. Definition acute, ascending bacterial infection of the biliary tree caused by an obstruction Bile duct inflammation a spectrum of disease presents variably with a wide range of severity Charcot triad with fever, jaundice, and right upper quadrant pain mental status changes and hypotension join Charcot triad to become Reynolds pentad 3 components 1. obstruction of bile flow 2. colonization of the bile with bacteria (bactobilia) or fungi 3. elevation of intraductal biliary pressure.
- 6. Effects of Biliary Obstruction Hepatobiliary Cardiovascular Renal Coagulation Immune System Wound healing Other problems
- 7. Hepatobiliary Bile duct obstruction Increased biliary pressure bile reflux into liver sinusoids inflammatory infiltration and fibrosis in the subepithelial layers of the biliary radicals. decreased capacity to excrete drugs, such as antibiotics, that are normally secreted into bile Decreased synthetic function of hepatocyte bile acids in high concentrations hepatocyte apoptosis Effects on Kupfer cells increase levels of proinflammatory cytokines, including TNF- α and IL-6
- 8. Cardiovascular Cause hemodynamic and cardiac disturbances Jaundiced patient more prone for shock In a study of 9 patients with obstructive or cholestatic Jaundice, Lumlertgul and colleagues (1991) showed a significantly blunted response in left ventricular ejection fraction compared with normal volunteers following the infusion of inotrope dobutamine. Biliary drainage is associated with increase in cardiac output, compliance, and contractility
- 9. Renal ANP Bile acids Endotoxemia AKI Renal Cortical and Tubular Necrosis
- 10. Coagulation endotoxin release in jaundiced patients results in a low- grade, disseminated intravascular coagulation with increased fibrin degradation products. Lack of intestinal bile Impaired absorption fat soluble vitamins including vit K, fat, calcium coagulopathy
- 11. Immune system Impaired T-cell proliferation, decreased neutrophil chemotaxis, defective bacterial phagocytosis Obstruction disruption of the enterohepatic circulation and results in loss of the emulsifying antiendotoxin effect of bile acids bacterial translocation and endotoxemia Cholangitis 1)significant bacterial concentration in bile, 2)Biliary obstruction
- 12. Wound healing Propylhydroxylase is an enzyme necessary for the incorporation of proline amino acid residues into collagen decreased activity of this enzyme diminished wound healing Other issues Lack of bile salts in intestine decreased appetite malnutrition weight loss
- 13. Investigations IMAGING Transabdominal Ultrasound demonstrate intrahepatic and extrahepatic biliary dilation presence of gallstones less than 10 mm in size and dilation of the CBD greater than 10 mm CBD stones Computed Tomography reveal inflammation and demonstrate thickness of the bile ducts. detect the complications of cholangitis, such as hepatic abscess and pylephlebitis(suppurative thrombosis of the portal vein) reveal etiologies of biliary obstruction, other than a CBD stone, such as a tumoral mass
- 14. Magnetic Resonance Cholangiopancreatography Noninvasive Purely diagnostic stones appear as hypointense defects cannot differentiate stones from air bubbles, sludge, or blood clots cannot detect stones less than 3 mm in size Impacted stones in the ampulla require evaluation of T1 images before and after gadolinium injection
- 15. Endoscopic Ultrasound Resolution less than 1mm Gold standard for detection of small gallstones or other etiologies Invasive, requires GA/ sedation Cannot be done in altered anatomy Direct Cholangiography Retrograde or percutaneous cholangiography first step of a therapeutic procedure Invasive Complication - biliary infection, pancreatitis, and hemorrhage
- 16. Lab workup CBC, BU, Cr, E LFT Amylase, Lipase Blood Culture Bile Culture
- 17. Management Hydration Antibiotics Polymicrobial in 30-80% cases Escherichia coli and Klebsiella, gram-positive aerobes, and enterococci – Most common biliary-enteric anastomosis or chronic biliary tract infection and elderly – anaerobes like Bacteroides and Clostridium previously instrumented biliary tract -- Pseudomonas or Serratia species Liver transplant patients – Candida, VRE local resistance patterns (“antibiotic-gram”) Piperacillin offers the advantage of gram-positive coverage, including enterococci, as well as anaerobic coverage (Thompson et al, 1990). Tazobactam, a β-lactamase inhibitor, extends the spectrum to cover organisms that have acquired resistance. hydration and antibiotics may improve the clinical condition in up to 80% of patients with acute cholangitis, 20% with clinical sepsis will require urgent biliary decompression
- 18. Duration of Antibiotic Therapy antibiotic therapy to continue until biliary obstruction is completely relieved, biochemical liver function tests have improved or normalized, and the patient is afebrile for at least 48 hours. residual calculi or incompletely relieved obstruction – risk of recurrent cholangitis should remain on oral antibiotics until the biliary obstruction is completely relieved trimethoprim/sulfamethoxazole and levofloxacin ciprofloxacin alone or in combination with metronidazole.
- 19. Extrahepatic Biliary Stone Obstruction - Procedures for Biliary Decompression Endoscopic Biliary Decompression Percutaneous Transhepatic Cholangiography and Drainage Open Common Bile Duct Exploration
- 20. Endoscopic Biliary Decompression side-viewing scope is used to visualize and cannulate the ampulla of Vater. Contrast is injected into the CBD under real-time fluoroscopy only in an amount that allows the level of the obstruction to be visualized, and a guidewire is passed across the obstruction. 1) external nasobiliary drainage (ENBD) 2) internal drainage
- 21. External Naso- Biliary Drainage(ENBD) Advantages (i) No additional EST is required (ii) Clogging in the tube (external drain) can be washed out (iii) Bile cultures can be done
- 22. Internal drainage Plastic stent placement Advantages – minimal or absent discomfort and limited electrolyte or fluid shifts relative to transnasal biliary drainage Disadvantages - stent clogging or loss of patency, risk of dislodgement Endoscopic sphincterotomy (EST) high-frequency electric surgical incision of the duodenal papilla, using a sphincterotome selectively inserted into the bile duct. Morbidity and mortality rates are much higher with sphincterotomy than with nasobiliary catheter drainage when patients are critically ill Sphincterotomy is contraindicated in the presence of coagulopathy, systemic sepsis, and hemodynamic instability, with the exception of those patients who have clinically deteriorated after initial medical therapy.
- 24. Percutaneous Transhepatic Cholangiography and Drainage(PTBD) in the presence of a hilar obstruction - malignant biliary obstruction Used in combination with expandable metallic stents
- 25. Open Common Bile Duct Exploration Indicated for patients who cannot undergo endoscopic drainage prior Roux-en-Y choledochojejunostomy or gastric bypass procedure T-tube placement without choledocholithotomy is recommended Steps : 1. exposure should be obtained along the free border of the lesser omentum, above the duodenum 2. aspiration with a fine needle to lacalise CBD 3. anterior vertical incision is made parallel to the long axis of the duct on the distal CBD, with stay sutures placed on either side 4. T-tube should be placed in the CBD above the level of the obstruction to externally decompress the biliary system and enable bile duct closure
- 26. Intrahepatic Biliary Stone Obstruction transhepatic percutaneous intracorporeal electrohydraulic shock- wave lithotripsy (ICSWL) yttrium-aluminum-garnet (YAG) laser lithotripsy Liver resection - to patients with associated atrophy of the involved segments
- 27. Recurrent Pyogenic Cholangitis(RPC) Oreintal Cholangiohepatitis recurrent episodes of bacterial cholangitis that occur in association with bile duct strictures, segmental biliary dilation with bile stasis, recurrent episodes of obstructive jaundice and ascending cholangitis, pigmented biliary calculi, and biliary cirrhosis. Clonorchis sinensis (liver fluke), ascaris lumbricoides eradicate the parasites with mebendazole and eliminate all biliary stones and strictures Choledochojejunostomy with a cutaneous limb
- 28. HIV/AIDS cholangiopathy Papillary stenosis PSC Biliary stricture Rx – EST HAART (Highly Active Antiretroviral Therapy)
- 29. Thank you
Editor's Notes
- #8: Normal biliary pressure – 10 mm H2O, Increased – 20- 30 mm H2O. The tight junctions between hepatocytes and bile duct cells are disrupted, resulting in an increase in bile duct and canalicular permeability. In the setting of biliary obstruction and elevated biliary pressure, bile becomes less lithogenic because of a relative decrease in cholesterol and phospholipid secretion compared with bile acid secretion. With the relief of biliary obstruction and the normalization of biliary pressures, the recovery of cholesterol and phospholipid secretion is more rapid than bile acid secretion, therefore bile is more lithogenic in this setting. This phenomenon may lead to premature occlusion of decompressive bilary stents placed for the management of obstructive jaundice.
- #10: ANP - depressed cardiac function ANP production due distension of atrium natriuresis, diuresis hypovolemia, hypotension Bile Acids- increased serum levels of bile acids associated with obstructive jaundice have a direct diuretic and natriuretic effect on the kidney that results in significant extracellular volume depletion and hypovolemia mediated by increased prostaglandin E2 (PGE2) by kidney. redistribution of renal blood flow away from the cortex. Endotoxin – 1) bile salts in the gut lumen prevent absorption of endotoxins, 2) decreased hepatic clearance of endotoxin by Kupffer cells Increased endotoxins renal vasoconstriction, redistribution of renal blood flow away from cortex renal cortical and tubular necrosis AKI.
- #12: Bacteria in bile - Escherichia coli, Klebsiella pneumonia, the enterococci, and Bacteroides fragilis – source? – CBD stones, instrumentation, other obstructive pathology
- #27: PTCD in the acute phase
- #28: Following standard cholecystectomy, a portion of the common duct is isolated for choledochoenteric anastomosis. A 60- to 70-cm segment of bowel is used for the Roux-en-Y limb, and a side-to-side choledochojejunostomy is then constructed 10 to 15 cm from the end of the jejunal limb. The blind limb of the jejunal access loop is then brought through the fascia of the abdominal wall in the right upper quadrant at a point that will allow straight access to the biliary tree. Lateral placement of the bowel, just below the skin, will help ensure that the interventional radiologist’s hands and instruments are not in the fluoroscopy beam. Although gross stones are removed, no attempt is made at complete clearance of the CBD or hepatic radicles. After closure of the abdomen, the stoma is matured in a “turn-back” fashion. The availability of the cutaneous stoma greatly facilitates subsequent treatment of the residual stones and strictures. After completion of radiologic treatment, the stoma is mobilized, closed, and left buried in the subcutaneous tissues for future access.