1.8.2 Choledolcolithiasis and Cholangitis

Question 1

What is choledocholithiasis? How prevelant amongst those with cholecystitis?

What are primary vs. secondary etiologies?

What is the common clinical presentation?

Answer 1

• Presence of gallstones in the CBD
• Occurs in 10-20% of acute cholecystitis patients
• Primary Etiology
  
  • Stones formed in the CBD as a result of biliary stasis
• Secondary Etiology
  
  • Stones migrate from gallbladder to the CBD
• Clinical presentation
  
  • Biliary colic-type pain (i.e. RUQ and/or epigastric)
  • Usually lasts longer than 6h (in contrast to colic)
  • N/V common
  • Usually afebrile
  • If duct blockage severe:
    
    • Jaundice
    • Courvoisier’s sign: Gbladder distended and palpable on abd exam

Question 2

You suspect choledocholithiasis. What is your diagnostic workup - labs? imaging? endoscopy?

Answer 2

• Labs
  
  • CBC, BMP, LFTs, amylase, lipase
    
    • Normal WBCs expected
    • LFTs = cholestatic pattern
      
      • Elevated Alk Phos and Bili
    • Pancreatic enzymes normal
  • Gamma-glutamyl transferase (GGT)
    
    • Elevated in CBD blockage
• Imaging
  
  • RUQ US initially
    
    • Dilated CBD > 6mm needs to be investigated due to high risk of stone in CBD
  • MRCP
    
    • MRI done to rule in/out presence of CBD stones
    • Use in pts with intermediate risk factors (10-50% likelihood for choledocholithiasis)
    • Pros: Non-invasive
    • Cons: Dx test only, not therapeutic
  • Endoscopic Ultrasound (EUS)
    
    • Good for evaluating biliary system d/t how close proximal duodenum is to extrahepatic bile duct
    • Useful in determining cause of dilated CBD if MRCP unrevealing
  • ERCP
    
    • Indication: High risk (>50%) of having choledocholithiasis
    • Pros: Dx AND therapeutic
    • COns: Invasive!
      
      • Sedation, risk for acute pancreatitis, risk for perforated esophagus/duodenum/pancreas, risk of bleeding

Question 3

• What is Cholangitis?
• What is Primary Sclerosing Cholangitis?
  
  • What are s/s at diagnosis?
  • How do you go about diagnosing?
• What causes Secondary Sclerosing Cholangitis?
• What are the most common symptoms of cholangitis?

Answer 3

• Cholangitis: obstruction of biliary tree
  
  • Depending on cause, can lead to sepsis and/or liver failure
• Primary Sclerosing Cholangitis
  
  • Chronic, progressive biliary tree inflammation & fibrosis
  • Uncommon; idiopathic but a/w IBD
  • Risk factor for cancer of gbladder, bile duct, colon
  • Can lead to progressive liver failure and liver txp
  • S/s at diagnosis
    
    • Hepatomegaly
    • Splenomegaly
    • Abd pain
    • Pruritis
    • Jaundice
    • Fatigue
  • Dx
    
    • Elevated Alk Phos > 6 months
    • Bile duct strictures on MRCP or ERCP
    • Tx: nothing definitive
• Secondary Sclerosing Cholangitis
  
  • Choledocholithiasis is most common cause
  • May have acute, sudden onset
• Symptoms
  
  • Charcot’s Triad
    
    • RUQ pain
    • Jaundice
    • Fever
  • Reynold’s Pentad
    
    • Charcot’s Triad
    • Mental status Changes
    • Hypotension

Question 4

How do you determine the severity of your patient’s cholangitis?

How do you treat it?

Answer 4

• Moderate cholangitis
  
  • Age < 75y
  • WBC >12 or <4
  • Temp > 39
  • Total bili > 5
  • Hypoalbuminemia
• Severe Cholangitis
  
  • AMS
  • Hotn req 5mcg/kg/min dopamine or any norepi
  • P/F < 300
  • Ologuria, Cr > 2mg/dL
  • INR > 1.5
  • Plt < 100k
  • Multi organ dysfunction/failure
• Treatment:
  
  • 2007 Tokyo Guidelines

Question 5

Describe the relationship btwn cholangitis and bacterial resistance?

Your cholecystitis/cholangitis pt needs empiric abx coverage. Describe the general approach depending on severity and where the pt acquired the infxn?

Answer 5

• In pts with biliary stents
  
  • Empiric therapy should cover enterococci and ESBL-producing enterobacteriaceae
• Empiric Abx approach
  
  • Cover gram neg
  • Cover pseudomonas
  • Cover anaerobes if severe
  • Cover MRSA if healthcare acquired

Question 6

Describe supportive care in acute cholangitis

Describe biliary drainage and biliary decompression

Answer 6

• Supportive Care
  
  • IV hydration
  • Lyte repletion
  • Analgesia
  • Monitor for organ dysfct and shock
• Biliary Drainage
  
  • Mild-mod cholangitis
  • Req within 24h
  • Open or laparoscopic surgery
  • Cholecystostomy tube placement
• Biliary Decompression
  
  • Severe cases
  • Req within 24h via ERCP
  • Sphincterotomy, stone extraction, stent placement

Question 7

In just a few words, differentiate cholelithiasis, choledocholithiasis, cholecystitis, and cholangitis

Answer 7

• Cholelithiasis
  
  • Stones in gallbladder
  • D/t aggregation/concentration of bile in gallbladder
  • Sx: RUQ pain, N/V
  • Dx: RUQ US
  • Tx: Elective cholecystectomy
• Choledocholithiasis
  
  • Stones in CBD
  • Sx: RUQ pain and jaundice
  • Dx: RUQ US, MRCP, ERCP
  • Tx: ERCP
• Cholecystitis
  
  • Inflammation of gallbladder and cystic duct
  • D/t obstruction of cystic duct
  • Sx: RUQ pain, N/V, fever
  • Dx: RUQ US, HIDA scan
  • Tx: Abx, cholecystectomy
• Cholangitis
  
  • Inflammation of the CBD/biliary tree
  • D/t obstruction of the CBD
  • Sx: RUQ pain, jaundice, fever
  • Dx: RUQ US, MRCP, ERCP
  • Tx: Abx, ERCP, cholecystectomy