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

Pancreatic cancer
Cholangiocarcinoma
Ampullary cancer
Porta hepatis

Others

Strictures/stenosis
ERCP
Sclerosing cholangitis
AIDS
Ascaris lumbricoides

Epidemiology

Nationality

Sex

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
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

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 defenseIgA 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 (2040%).

Adam.about.com

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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

Charcots
Triad:
Found in
50-70%
of
patients

Reynolds
Pentad:

Diagnosis: lab values

CBC
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

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

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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 Charcots 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

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 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:

ERCP attempted

Duct unable to cannulate due to presence of duodenum diverticulum at site

of ampulla of Vater

Laparoscopic cholecystectomy planned

No acute distress, reasonably soft abdomen

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 1020% 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

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

Laparoscopic CBD exploration

Most surgeons prefer less invasive techniques

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

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

Open surgery vs Endoscopic

sphincterotomy

In patients with intact gallbladders, ES or open choledochotomy?

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: 627-34

Cochraine database of systematic reviews

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?

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

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

Transcystic approach

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

High rate of lap CBD clearance: 73-100%

Conversion to open 5.2-19.6%

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

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

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

Cholecystectomy

Due to previous failure of ERCP due to duodenum diverticulum

Incision joining epigastric port with subcostal inciion
Dis
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.