Choledocholithiasis

1、Cholangitis &Management of CholedocholithiasisRuby Wang MS 3Surg 300A8/20/07ContentCaseCholangitisClinical manifestationsDiagnosisTreatmentDiagnosis and management of choledocholithiasisPre-operativeIntra-operativePost-operativeCaseHPI: 86 yo lady p/w 3-4 episodes of RUQ/mid-epigastric abdominal pai

2、n over the last year, lasting generally several hours, accompanied by occasional emesis, anorexia, and sensation of shaking chills. ROS: negative otherwisePE: VS: T 36.2, P98 , RR 18, BP 124/64Abdominal exam significant for RUQ TTPLabsAST 553, ALT 418. Alk Phos 466. Bilirubin 2.7WBC 30.3ImagingAbdom

3、inal US: multiple gallstones, no pericholecystic fluid, no extrahepatic/intrahepatic/CBD dilatationIntroductionCholangitis is bacterial infection superimposed on biliary obstructionFirst described by Jean-Martin Charcot in 1850s as a serious and life-threatening illnessCausesCholedocholithiasisObstr

4、uctive tumorsPancreatic cancerCholangiocarcinomaAmpullary cancerPorta hepatisOthersStrictures/stenosisERCPSclerosing cholangitisAIDSAscaris lumbricoidesEpidemiologyNationalityU.S: uncommon, and occurs in association with biliary obstruction and causes of bactibilia (s/p ERCP)Internationally: Orienta

5、l cholangiohepatitis endemic in SE Asia- recurrent pyogenic cholangitis with intrahepatic/extrahepatic stones in 70-80% Gallstones highest in N European descent, Hispanic populations, Native AmericansIntestinal parasites common in AsiaSexGallstones more common in womenM: F ratio equal in cholangitis

6、AgeMedian age between 50-60Elderly patients more likely to progress from asymptomatic gallstones to cholangitis without colic PathogenesisNormally, bile is sterile due to constant flush, bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duoden

7、al reflux and ascending infectionERCP 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 pressureHigh pressure diminishes host antibacterial defense-

8、IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization. Bacteria gain access to biliary tree by retrograde ascentBiliary obstruction (stone or stricture) causes bactibiliaE Coli (25-50%) Klebsiella (15-20%), Enterobacter (5-10%)High pressure pushes infec

9、tion into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%). AGpnotebook.co.ukPClinical ManifestationsRUQ pain (65%)Fever (90%)May be absent in elderly patientsJaundice (60%)Hypotension (30%)Altered mental status (10%)Char

10、cots Triad:Found in 50-70% of patientsReynolds Pentad: Additional HistoryPruitus, acholic stoolsPMH for gallstones, CBD stones, Recent ERCP, cholangiogramAdditional Physical TachycardiaMild hepatomegalyDiagnosis: lab valuesCBC79% of patients have WBC 10,000, with mean of 13,600Septic patients may be

11、 neutropenicMetabolic panelLow calcium if pancreatitis88-100% have hyperbilirubinemia 78% have increased alkaline phosphataseAST and ALT are mildly elevatedAminotransferase can reach 1000U/L- microabscess formation in the liverGGT most sensitive marker of choledocholithiasisAmylase/LipaseInvolvement

12、 of lower CBD may cause 3-4x elevated amylaseBlood cultures20-30% of blood cultures are positiveDiagnosis: first-line imagingUltrasonographyAdvantage: Sensitive for intrahepatic/extrahepatic/CBD dilatation CBD diameter 6 mm on US associated with high prevalence of choledocholithaisisOf cholangitis p

13、atients, dilated CBD found in 64%,Rapid at bedsideCan image aorta, pancreas, liverIdentify complications: perforation, empyema, abscessDisadvantageNot useful for choledocholithiasis: Of cholangitis patients, CBD stones observed in 13% 10-20% falsely negative - normal U/S does not r/o cholangitisacut

14、e obstruction when there is no time to dilateSmall stones in bile duct in 10-20% of cases CTAdvantagesCT cholangiograhy enhances CBD stones and increases detection of biliary pathologySensitivity for CBD stones is 95%Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscess

15、Can visualize other pathologies- cholangitis: diverticuliits, pyelonephritis, mesenteric ischemia, ruptured appendixDisadvantagesSensitivity to contrastPoor imaging of gallstonesMSoto et al. J. Roenterology. 2000Diagnostic: MRCP and ERCPMagnetic resonance cholangiopancreatography (MRCP)AdvantageDete

16、cts choledocholithiasis, neoplasms, strictures, biliary dilationsSensitivity of 81-100%, specificity of 92-100% of choledocholithiasisMinimally invasive- avoid invasive procedure in 50% of patientsDisadvantage: cannot sample bile, test cytology, remove stoneContraindications: pacemaker, implants, pr

17、osthetic valves IndicationsIf cholangitis not severe, and risk of ERCP high, MRCP usefulIf 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 O

18、ddi dysfunctionAdvantageTherapeutic option when CBD stone identifiedStone retrieval and sphincterotomyDisadvantageComplications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleedingDiagnostic ERCP complication rate 1.38% , mortality rate 0.21%Medical TreatmentResucitate, Monitor

19、, Stabilize if patient unstableConsider cholangitis in all patients with sepsisAntibioticsEmpiric broad-spectrum Abx after blood cultures drawnAmpicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)Carbapenems: gram negative, enterococcus, anaerobesLevofloxacin (250-500mgIV qD) for impaired renal

20、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 confusionSurgical treatmentEndoscopic biliary drainageEndoscopic sphincterotomy with

21、stone extraction and stent insertionCBD stones removed in 90-95% of casesTherapeutic mortality 4.7% and morbidity 10%, lower than surgical decompressionSurgeryEmergency surgery replaced by non-operative biliary drainageOnce acute cholangitis controlled, surgical exploration of CBD for difficult ston

22、e removalElective surgery: low M & M compared with emergency surveyIf emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD explorationOur caseCondition: No acute distress, reasonably soft abdomenERCP attemptedDuct unable to cannulate due to presence of duodenum d

23、iverticulum at site of ampulla of VaterLaparoscopic cholecystectomy plannedDissection of triangle of CalotCystic duct and artery visualized and dissectedCystic duct ductotomyInsertion of cholangiogram catheter advanced and contrast bolused into cystic duct for IOCIntraoperative cholangiogramSeveral

24、common duct filling defects consistent with stonesDecision to proceed with CBD explorationCholedocholithiasisCholedocholithiasis develops in 10-20% of patients with gallbladder disease At least 3-10% of patients undergoing cholecystectomy will have CBD stonesPre-opIntra-opPost-opPre-op diagnosis & m

25、anagementDiagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCPHigh risk (50%) of choledocholithiasis: clinical jaundice, cholangitis,CBD dilation or choledocholithiasis on ultrasoundTbili 3 mg/dL correlates to 50-70% of CBD stoneModerate risk (10-50%): h/o pancreatitis, jaundice correl

26、ates to CBD stone in 15%elevated preop bili and AP, multiple small gallstones on U/SLow risk ( 6mmvia cystic duct (66-82.5%)CBD clearance rate 97%Morbidity rate 9.5%Stones impacted at Sphincter of Oddi most difficult to extractIntraoperative ERCPEarly years: Open CBD exploration & Introduction of en

27、doscopic sphincterotomy1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon Kocherization of duodenum and short longitudinal choledochotomyStones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainageFor many years, this was the standard trea

28、tment for cholecystocholedocholithiasis1970s, endoscopic sphincterotomy (ES)Gained wide acceptance as good, less invasive, effective alternativeIn patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choiceOpen surgery vs Endoscopic sphincterotomyIn patients wi

29、th intact gallbladders, ES or open choledochotomy?Design: 237 patients with CBD stone and intact gallbladders, 66% managed with ES and rest with open choledochotomyResults: No significant difference in morbidity and mortality ratesLower incidence of retained stones after open choledochotomyConclusio

30、n: open surgery superior to ES in those with intact gallbladdersMiller et al. Ann Surg 1988; 207: 135-41Is 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. An

31、n Surg 1991; 213: 627-34Cochraine database of systematic reviewsDesign:8 trials randomized 760 patients comparing ERCP with open surgical clearanceResults: Open surgery more successful in CBD stone clearance, associated with lower mortalityConclusion: open bile duct surgery superior to ESCochrane da

32、tabase of systematic reviews 2007In 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 choledochotomyResults:In group managed initially with endoscopic drai

33、nage, need for ventilatory support (29% vs 63%) and mortality (33% vs 66%) significantly lessConclusion: toxic cholangitis should managed with endoscopic sphincterotomyLai et al. J Engl J Med 1992; 326: 1582-6Laparoscopic CBD ExplorationIn 1989, laparoscopic removal of gallbladder replaced open surgeryIn the past decade, laparoscopic CBD exploration (LCBDE) developedTechniquesIOC define biliary anatomy: size and length of cystic duct, size of bile duct stonesCholedochotomyIf cysti