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Biliary Emergencies

Murad Aljiffry MD FRCSC


Case 1

61 year old male


Abdominal pain for 5 days
Associated with:
Fever, malaise, chest pain with
shortness of breath and anorexia
Past Hx.: diverticulitis treated
Physical examination
HR 120, B/P 100/60
Localized RUQ peritoneal findings
Case 1

Lab:
WBC: 18, Hb: 10,
Creat 130, T.bili 60, ALP 350, Alb 25
US:
Hypoechoic liver lesion with thickened
irregular wall
Gall stones

What next?
Case 1

Abdominal CT (contrast-enhanced)
Hypodense lesion of left lobe(5.5cm)
occupies segment II and III
well demarcated, round
Liver Abscess

Pyogenic(80%): E. coli, K.P


Paracytic(10%): Entamaeba
histolytica
Others(10%): candida
Epidemiology

Incidence in the US is 8-15 per


100,000
Male to female ratio is 2:1 in recent
studies
5th-7th decades of life
Risk factors : DM, underlying
hepatobiliary or pancreatic
malignancy, and liver transplant
Etiology

Biliary disease accounts for 20-40%


Extrahepatic obstruction leading to
ascending cholangitis and abscess
CBD stones
Benign and malignant tumors
Biliary enteric anastamoses or
manipulation
Etiology

Infection via portal system


Infectious process originates in
abdomen, reaches liver by
embolization through portal system
Appendicitis, diverticulitis, IBD,
proctitis
Etiology

Hematogenous via hepatic artery


From systemic septicemia such as
endocarditis and pyelonephritis
Direct extension or trauma
No cause (cryptogenic) in 20-40% of
cases
Etiology

Underlying etiology of 1086 cases of liver abscess compiled


from the literature
Microbiology

Most contain more than one organism


Blood cultures positive in 33-65%
E.Coli
Klebsiella (is an important emerging
infection associated with endophthalmitis )
Bacteroides
Streptococcal (including S. aureus and S.
pyogenes)
Candida species : usually occurs in
immunosuppressed patients
Microbiology

Microbiologic results from 312 cases of liver abscess compiled


from the literature
Clinical

Fever (85-100%), abdominal pain


(50-75%)
About one-half of patients with liver
abscess have hepatomegaly, RUQ
tenderness, or jaundice
Right shoulder pain, pleuritic chest
pain
Anorexia, weight loss, mental
confusion
Diagnosis-Lab

CBC: anemia in 50-80%, leukocytosis


in 75-96%
LFTs: elevated alkaline phosphatase
95-100%, elevated AST, ALT 40-60%
Elevated bilirubin in 20-50%
Decreased albumin in 71-87%
Diagnosis-Imaging

CT and ultrasound are the modalities


of choice (80-100% sensitive)
An abscess appears radiologically as a
fluid collection with surrounding
edema and inflammation (rim
enhancement) that may contain
loculated subcollections and gas
Treatment

Initiation of antibiotic therapy


Diagnostic aspiration and drainage of
abscess
Surgical drainage in selected patients
Antibiotic Therapy

Empiric broad-spectrum antibiotics


(draw blood culture before)
A third generation cephalosporin such
as ceftriaxone + metronidazole
Fluoroquinolone (eg, ciprofloxacin) +
metronidazole
Monotherapy with a carbapenem or
an extended spectrum penicillin
Antibiotic Therapy

Immunocompromised patients with


multiple abscesses are best treated
with high dose antibiotics rather than
open or percutaneous drainage
Drainage

For single abscesses with diameter 5 cm :


percutaneous catheter drainage or needle
aspiration is acceptable (usually multiple)
For single abscesses with diameter >5 cm :
Percutaneous management (catheter drainage
no needle aspiration)
Some favor surgical intervention over
percutaneous drainage, treatment failure lower
with surgical drainage
Success 70-90%
Complications of
Percutaneous Drainage
Perforation of a viscous
Pneumothorax
Bleeding
Leakage of pus into the abdomen
Surgical Therapy

Indications of surgical drainage:


Co-existing intra-abdominal disease that
requires operative management
Failure of percutaneous drainage
Multiple abscesses
Loculated abscesses
Abscesses with viscous contents
obstructing the drainage catheter
Ascites or coagulopathy
Surgical Therapy

Transthoracic, extraperitoneal,
transperitoneal
Transperitoneal is preferred as intra-
abdominal pathology can be dealt
with
Laparoscopic or open
Duration of therapy

Follow imaging, WBC count and


serum CRP
Drainage catheters should remain in
place until drainage is minimal
Patients should be treated for 2-4
weeks
Complications

Result from rupture of abscess into


adjacent organs or cavities
Pleuropulmonary include effusions,
empyema, bronch-hepatic fistula
Intraabdominal include subphrenic
abscess, rupture into peritoneal
cavity, or any intraabdominal organ
Prognosis

Mortality rate : 10- 20%


If untreated fatal (100% mortality rate)
Mortality appears to be related to
underlying comorbidities rather than to the
abscess itself
Poor prognosis: age >70, multiple
abscesses, polymicrobial infection,
immunosupression, malignancy, and delay
diagnosis
Questions?
Case 2

40 y.o. female presents to ER with 12


hr history of upper abdominal pain
and fever
Associated nausea and vomiting
Lab: wbc 12, AST100, ALT220,
GGT1400, ALP 1340, Tbili 75
Case 2

Amylase and Lipase slight elevation


U/S multiple small stones in
gallbladder, CBD9mm, no intrahepatic
dilatation

What next?
Case 2

H/O gastric bypass


2:00 am
Acute Cholangitis

Pus under pressure


May be difficult to distinguish from
acute cholecystitis
Managed medically with support,
antibiotics
Drainage is key
Etiology

Stone disease
Anomalous PBJ
Malignant biliary obstruction
Primary sclerosing cholangitis
Post instrumentation
Cholangiography
Surgery
Sphincterotomy
Stents
Microbiology

80% patients +ve biliary cultures


(multiple organisms frequent )
E.Coli (commonest)
Enterococci
Klebsiella sp
Proteus sp
Pseudomonas sp
Bacteroides sp
Clinical Presentation

Charcots triad
Pyrexia, Pain, Jaundice
Elevated liver enzymes
Leukocystosis
Diagnosis

Clinical
Ultrasound
Duct dilation
Presence of gallbladder or CBD stones
CT
Duct dilation
R/O other causes
MRCP (especially for hilar obstruction, if
stable pt.)
ERCP (generally for therapy)
Management

Fluid resuscitation
Triage (floor or ICU)
Correction of coagulopathy and
electrolytes
Blood cultures
Antibiotics (broad spectrum)
Management

Most pt will respond and will require


urgent biliary decompression

10-15% of patients fail to respond or


deteriorate within 12-24 hours, thus
require emergent biliary
decompression
Biliary Drainage

Endoscopic
Surgical
Percutaneous
Endoscopic Biliary Drainage

Can be done at bedside in ICU with


portable flouroscopy
Superior to surgical drainage
Mortality of endoscopic vs surgical drainage
10% vs 32% RCT (Lai NEJM 1992)
Preferable to percutaneous drainage
Morbidity less (Sugiyama Arch Surg 1997,
AmJGastro 1998)
Especially in presence of ascites, coagulopathy
Endoscopic Biliary Drainage

Sphincterotomy
Caution due to bleeding risk
Stone removal
Stent
Percutaneous Biliary drain

When endoscopic drainage fails


Inaccessible papilla
Roux-en-Y
Hepatolithiasis
Segmental cholangitis (complex hilar
tumor)
Surgical Biliary drain

Last resort
Decompression of biliary tree and
placement of T tube
Questions?