Choledocholithiasis & Cholangitis

For further information, see CMDT Part 16-23: Choledocholithiasis & Cholangitis

Essentials of Diagnosis

• Often a history of biliary pain, which may be accompanied by jaundice

• Occasional patients present with painless jaundice

• Nausea and vomiting

• Cholangitis should be suspected with fever, which may be followed by hypothermia, jaundice, leukocytosis and gram-negative shock

• Stones in common bile duct most reliably detected by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography

General Considerations

• Bile duct stones usually originate in the gallbladder but may also form spontaneously in the common bile duct after cholecystectomy

• Symptoms, including those of cholangitis, result if there is obstruction

• Biliary pain results from rapid increases in bile duct pressure due to obstructed bile flow

Demographics

• About 15% of patients with gallstones have choledocholithiasis (common bile duct stones)

• The percentage rises with age, and the frequency in elderly people with gallstones may be as high as 50%

Symptoms and Signs

• See Table 16–9

• Biliary pain with jaundice in choledocholithiasis

• Frequently recurring attacks of right upper abdominal pain that is severe and persists for hours

• Chills and fever associated with severe pain in acute cholangitis

• Charcot triad (pain, fever [and chills], and jaundice) is characteristic of acute cholangitis

• Additional symptoms of altered mental status and hypotension (Reynold pentad) signifies acute suppurative cholangitis and is an endoscopic or surgical emergency

• According to the Tokyo guidelines, either of the following needs to be present to establish the diagnosis of acute cholangitis:

  • The full Charcot triad or

  • Two elements of the Charcot triad plus laboratory evidence of an inflammatory response (eg, elevated WBC count, C-reactive protein), elevated liver test results, and imaging evidence of biliary dilatation or a cause of obstruction

• Hepatomegaly may be present in calculous biliary obstruction, and tenderness is usually present in the right upper quadrant and epigastrium

Differential Diagnosis

• Cancer of the pancreas, ampulla of Vater, or bile ducts

• Acute hepatitis

• Biliary stricture

• Chronic cholestatic liver disease, eg, primary biliary cholangitis, primary sclerosing cholangitis, drug toxicity

• Pancreatitis

• Sepsis due to other causes

• Underlying Ascaris or Clonorchis, or hydatid disease

Laboratory Tests

• Bilirubinuria and elevated serum bilirubin

  • Present if the common bile duct is obstructed

  • Levels commonly fluctuate

• Serum alkaline phosphatase levels rise more slowly

• Serum amylase elevations may be present in secondary pancreatitis

• Acute obstruction of the common bile duct typically produces a transient striking increase in serum aminotransferase levels (> 1000 units/L [20 mckat/L])

• Prolongation of the prothrombin time can result from obstructed flow of bile to the intestine

• When extrahepatic obstruction persists for more than a few weeks, differentiation of common bile duct obstruction from chronic cholestatic liver disease becomes progressively more difficult

Imaging Studies

• Ultrasonography and CT demonstrate dilated bile ducts

• Radionuclide imaging may show impaired bile flow

• Endoscopic ultrasonography, helical CT, and MR cholangiography can accurately demonstrate common bile duct stones and, if available, may be used when there is intermediate risk for choledocholithiasis

Diagnostic Procedures

• ERCP (occasionally with intraductal ultrasonography) or percutaneous transhepatic cholangiography is the best means to determine the cause, location, and extent of obstruction

• However, in patients at intermediate risk for choledocholithiasis, initial cholecystectomy and intraoperative cholangiography results in a shorter length of hospital stay, fewer common bile duct investigations, and no increase in morbidity

• If the likelihood that obstruction is caused by a stone or that cholangitis is present is high, ERCP is the procedure of choice because it permits sphincterotomy with stone extraction or stent placement

Medications

Hypoprothrombinemia

• Intravenous vitamin K 10 mg or water-soluble oral vitamin K (phytonadione, 5 mg) in 24–36 hours

• For mild-to-moderately severe community-acquired acute cholangitis

  • Ciprofloxacin, 400 mg intravenously every 12 hours, with metronidazole, 500 mg every 6–8 hours intravenously for anaerobic coverage

  • Alternative regimen is ampicillin-sulbactam (3 g every 6 hours intravenously)

• Regimens for patients with severe or hospital-acquired acute cholangitis and those potentially infected with an antibiotic-resistant pathogen include

  • Piperacillin-tazobactam, 3.375 or 4 g intravenously every 6 hours or

  • Meropenem, 1 g every 8 hours intravenously

• Aminoglycosides (eg, gentamicin 5–7 mg/kg every 24 hours intravenously)

  • May be added in cases of severe sepsis or septic shock However, they should not be given for more than a few days because the risk of nephrotoxicity is increased in patients with cholestasis

• Regimens that include drugs active against anaerobes are required when a biliary-enteric communication is present

Surgery

• At cholecystectomy, operative cholangiography via the cystic duct should be considered

• If stones are found in the common bile duct, common bile duct exploration can be performed or a postoperative ERCP and sphincterotomy can be planned

• Choledocholithiasis discovered at laparoscopic cholecystectomy may be managed via laparoscopic removal or, if necessary, conversion to open surgery or by postoperative endoscopic sphincterotomy

• Cholecystectomy may be deferred after endoscopic sphincterotomy in elderly (age > 70 years) or poor-risk patients with cholelithiasis and choledocholithiasis because risk of subsequent cholecystitis is low

Therapeutic Procedures

• A common bile duct stone with underlying cholelithiasis is usually treated by endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy within 72 hours in patients with cholecystitis and within 2 weeks in those without cholecystitis

• Laparoscopic cholecystectomy and common bile duct exploration is an alternative approach, which may be associated with a shorter duration of hospitalization

• ERCP with sphincterotomy should be performed before cholecystectomy in patients with gallstones and jaundice (serum total bilirubin > 4 mg/dL [68.4 mcmol/L]), a dilated common bile duct (> 6 mm), or stones in the common bile duct seen on ultrasonography or CT

• Endoscopic ultrasound-guided biliary drainage or percutaneous transhepatic cholangiography (PTC) with drainage are second-line approaches if ERCP fails or is not possible

• Endoscopic balloon dilation of the sphincter of Oddi

  • May be associated with a higher rate of pancreatitis than endoscopic sphincterotomy unless adequate dilation for > 1 min is carried out

  • Is generally reserved for patients with coagulopathy because the risk of bleeding is lower with balloon dilation than with sphincterotomy

• When biliary pancreatitis resolves rapidly, the stone usually passes into the intestine, and ERCP prior to cholecystectomy is not necessary if an intraoperative cholangiogram is planned

• In the postcholecystectomy patient with choledocholithiasis, endoscopic papillotomy with stone extraction is preferable to transabdominal surgery

• Lithotripsy (endoscopic or external), peroral cholangioscopy (choledoscopy), or biliary stenting may be therapeutic for large stones

• For the patient with a T tube and common bile duct stone, the stone may be extracted via the T tube

• Emergent decompression of the common bile duct, generally by ERCP, sphincterotomy, and stone extraction, is generally indicated for patients with acute cholangitis who are septic or do not improve on antibiotics within 12–24 h

• If sphincterotomy cannot be performed, the common bile duct can be decompressed by a biliary stent or nasobiliary catheter

• Once decompression is achieved, antibiotics are generally continued for another 3 days

Follow-Up

• Postoperative antibiotics are not given routinely after biliary tract surgery, but intraoperative bile cultures are taken

• If biliary tract infection was present preoperatively or is apparent at operation, antibiotics are administered postoperatively until the results of sensitivity tests on culture specimens are available

  • Ampicillin-sulbactam (3 g every 6 hours intravenously) or

  • Piperacillin-tazobactam (3.375 or 4.5 g every 6 hours intravenously) or

  • A third-generation cephalosporin (eg, ceftriaxone, 1 g every 24 hours intravenously)

• A T-tube cholangiogram should be done before the tube is removed, usually about 3 weeks after surgery

• A small amount of bile frequently leaks from the tube site for a few days

Complications

• Common bile duct obstruction lasting longer than 30 days results in liver damage leading to cirrhosis

• Hepatic failure with portal hypertension occurs in untreated cases

Prognosis

• Medical therapy alone for acute cholangitis is most likely to fail in patients with

  • Tachycardia

  • Serum albumin < 3 g/dL (30 g/L)

  • Marked hyperbilirubinemia

  • High serum ALT level

  • High WBC count

  • Prothrombin time > 14 seconds on admission

• Mortality from acute cholangitis has been reported to correlate with a high total bilirubin level, prolonged partial thromboplastin time, presence of a liver abscess, and unsuccessful ERCP

When to Refer

• All symptomatic patients with choledocholithiasis should be referred

When to Admit

• All patients with acute cholangitis should be hospitalized