JC63C (Surgery) - Cholangitis and Cholecystitis Flashcards
Major etiologies of acute cholecystitis
Acute cholecystitis
• Calculous cholecystitis (90 – 95%): Obstruction of the cystic duct by an impacted gallstones
• Acalculous cholecystitis
• Tumour obstructing the cystic duct (<1%)
Acute cholecystitis:
Bacteria in bile: gram negative rods, enterococci
Bile duct obstruction: Stones, tumors, benign strictures
Pathogenesis of chronic cholecystitis /
Associated with presence of gallstones: mechanical irritation or recurrent attacks of acute cholecystitis leading to fibrosis and thickening of gallbladder
Acalculous cholecystitis
- Demographic
- Associated diseases
- Pathogenesis
- S/S
- Dx and Tx
Demographic: patients with other acute systemic diseases or critically-ill patients
Associated diseases: TPN, extensive burns, sepsis, major operations, multiple trauma or prolonged illness with multi-organ dysfunction are at risk
Pathogenesis: NOT associated with presence of gallstone, gallbladder distension with bile stasis and ischemia
S/S: fever, RUQ pain and leukocytosis
Dx and Tx:
- USG and HIDA scan
- Urgent systemic antibiotics + percutaneous USG/CT-guide cholecystostomy or interval cholecystectomy
Pathogenesis of cholecystitis /
3 steps:
Cystic duct obstruction >>> distension, inflammation and edema of gallbladder wall
Bile stasis >>> chemical irritant such as lysolecithin (mucosal toxin in bile) cause inflammation in gallbladder
Infection of biliary system >>> Secondary bacterial contamination/ Infected bile by E. coli, Enterobacter, Klebsiella and Enterococcus sp.
Abdominal pain characteristics of acute cholecystitis
(SOCRATES)
Abdominal pain
• Site: RUQ or epigastrium
• Onset: Sudden onset
• Character: Steady
• Radiation: Right shoulder (interscapular area) (Boas sign) or back
• Associated symptoms: Fever, anorexia, nausea and vomiting
• Time course: Prolonged for > 4 – 6 hours
• Exacerbating factors: Movement
• Reliving factors: Rest (Reluctant to move)
• Severity: Severe
Ddx acute cholecystitis
• Biliary colic: gallbladder contraction against gallbladder obstruction after fatty meal
- Peptic ulcer disease (PUD)
- Acute pancreatitis
- Acute appendicitis
- Acute hepatitis
- Irritable bowel syndrome
- Sphincter of Oddi dysfunction
- Pneumonia
- Pleuritis
- Myocardial infarction (MI)
Complications of cholecystitis
Gallbladder:
- Mucocele, Empyema, Rupture
Acute cholangitis
Acute pancreatitis
Cholecysteoduodeno-fistula
Liver abscess
…etc
Acute cholecystitis
Diagnostic criteria /
Diagnostic criteria (Tokyo criteria 2013)
Diagnostic components
• A: Local signs of inflammation
o Murphy’s sign
o RUQ mass/ pain/ tenderness
• B: Systemic signs of inflammation
o Fever
o Leukocytosis
o Elevated CRP level
• C: Imaging findings
o Imaging findings characteristic of acute cholecystitis
Definite diagnosis = One time in A + One item in B + One time in C
P/E signs of acute cholecystitis
General examination
• Ill-appearance lying still on bed - peritoneal inflammation, Jaundice, Fever, Tachycardia
Abdominal exam:
Localized RUQ tenderness
• Guarding
• Rigidity
• Murphy’s sign* Gallbladder pain with breathing > grasp for air***
First-line investigations for acute cholecystitis
Blood:
- CBC with differentials
- LFT
• Liver chemistry is usually NORMAL +/- mild elevation of bilirubin, ALP, transaminases and amylase
Radiological:
- Abdominal USG: presence of gallstones + Gallbladder distention, edema, wall thickening, Sonographic Murphy’s sign
- Radionucleotide Cholescintigraphy (HIDA scan): Tc-99m HIDA for visualization of biliary system, show failure of gallbladder to fill with dye
- MRCP: intra-hepatic and extrahepatic ducts
- CT abdomen: detect complications
First-line treatment for acute cholecystitis
1. General
Nil by mouth (NPO)
vitals
Blood test including cross-match
- Medical treatment
IV fluids
Analgesics: NSAIDs
IV Antibiotics: vs secondary infection and complications
Empirical antibiotics should cover for gram -ve aerobes and anaerobes: Cefuroxime, Metronidazole, Piperacillin + Tazobactam/ Tazocin
Surgical treatment options for acute cholecystitis **
Surgical resection:
- Open/ Laparoscopic cholecystectomy
- Early laparoscopic cholecystectomy (48-72h)
- Delayed/ interval laparoscopic cholecystectomy (6-10weeks)
Gallbladder drainage:
- Percutaneous cholecystostomy
- Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD)
- Endoscopic transpapillary drainage by ERCP (ETGBD)
Compare open vs Laparoscopic cholecystectomy
Pros and cons
Open:
- Lower complications
- Lower conversion rate
- More pain, Longer hospital stay
Laparoscopic:
- Less pain
- Shorter hospital stay
- Faster recovery
- Better cosmesis
- CONS: Higher conversion rate, Higher complication rate, More technically demanding
Compare early vs Delayed/ interval laparoscopic cholecystectomy
Early cholecystectomy should always be recommended unless contraindicated
Gallbladder drainage for acute cholecystitis **
- Indications
- Methods
- *Indication**
- *o Severe acute cholecystitis (Grade III)/ difficult cholecystectomy**
- *o Hemodynamically unstable**
- *o Failure of medical (antibiotic) therapy**
- *o High surgical risk**
Methods:
Percutaneous cholecystectomy **
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD)
Endoscopic transpapillary drainage by ERCP (ETGBD)
Acute cholangitis /
Pathogenesis
Obstruction with bacterial overgrowth = Acute cholangitis (infection of bile duct)
Biliary obstruction and stasis predisposes to bacterial infection of biliary tree
o Ascending infection from duodenum
o Hematogenous spread from portal veins
Disrupted normal barrier mechanism
• Normal barrier is disrupted after endoscopic sphincterotomy, biliary stent insertion and choledochal surgery
• Incomplete biliary drainage or biliary stent blockage or Presence of foreign body serves as a nidus for bacterial colonization
Acute cholangitis
Etiologies/ Causes
- * Choledocholithiasis (most common)**
- * Benign or malignant strictures (MBO)** of bile ducts or at biliary-enteric anastomosis
- * Indwelling stents (stent occlusion)** or instrumentation of ducts
- * Tumours**
- * Parasitic infection**
S/S of acute cholangitis
- *Charcot’s triad (present in 2/3 of patients)**
- *• Fever**
- *• Abdominal pain**
- *• Jaundice**
Reynolds pentad (present in < 10% of patients)
• Fever
• Abdominal pain
• Jaundice
• Hypotension (septic shock)
• Altered mental status (Confusion)
Ddx acute cholangitis
Differential diagnosis of fever and abdominal pain
• Recurrent pyogenic cholangitis
• Acute cholecystitis
• Acute pancreatitis
• Acute appendicitis
• Liver abscess
• Biliary leaks
Diagnostic criteria of Acute cholangitis /
Diagnosis should be suspected if the patient
• Has ONE of the following (AND)
o Fever or shaking chills
o Laboratory evidence of an inflammatory response (Abnormal WBC/ Increased CRP/ Other changes suggestive of inflammation)
• Has ONE of the following
o Jaundice
o Abnormal liver chemistries (Increased AST/ ALT/ ALP/ GGT)
Diagnosis is considered definite if, in addition to meeting the criteria for a suspected diagnosis
• Has BOTH of the following
o Biliary dilation on imaging
o Evidence of an etiology on imaging such as stone, stricture or stent
First-line investigations for acute cholangitis
Blood:
CBC with differentials: Leukocytosis with neutrophil predominance
Clotting profile
Inflammatory markers: ↑ ESR and CRP
LFT: ↑ ALP and GGT (Cholestatic pattern) + ↑ Conjugated bilirubin
RFT
Urinalysis: Conjugated bilirubin
Blood/ Bile culture + antibiotics susceptibility test
Radiological:
Transabdominal ultrasound (USG)
Endoscopic retrograde cholangiopancreatography (ERCP)
Magnetic resonance cholangiopancreatography (MRCP)
First-line management of acute cholangitis
General:
- Monitor vitals for shock
- Manage sepsis
- Supportive fluid resuscitation
Medical:
- Analgesics
- IV fluid resuscitation
- IV antibiotics: Cefuroxime, Metronidazole, Piperacillin + Tazobactam
Biliary decompression and drainage:
- Endoscopic = ERCP
- Radiologic (Percutaneous) = PTBD/ Percutaneous cholecystostomy
- Surgical = Decompression by ECBD
Surgical treatment for acute cholangitis
Complications
Options
o Endoscopic = **ERCP** o Radiologic (Percutaneous) = **PTBD/ Percutaneous cholecystostomy** **o Decompression by ECBD**
(Bypass/ Resection)
Complications:
Perforation, bleeding from papillotomy, pancreatitis
ECBD and surgical biliary drainage for acute cholangitis
Indications for each
ECBD:
Failed endoscopic drainage/ Deterioration despite Tx
Open approach for emergency
Surgical drainage:
Choledocholithiasis: Laparoscopic/ Open ECBD with removal of stones and placement of T-tube (OR) Cholecystectomy
Malignant biliary obstruction (MBO): Whipple’s or Bypass (Hepaticojejunostomy/ Choledochojejunostomy)
ERCP interventional modalities
Papillary balloon dilation (Balloon sphincteroplasty)
Stone retrieval: Balloon catheter, Baskets
ERCP with endoprosthesis (endoscopic stenting)/ Nasobiliary catheter
