Acute Cholangitis 20 Gary Gecelter That an emergency operation is very rarely indicated in acute cholangitis does not mean that it is never indicated. What is the Mechanism? Acute ascending cholangitis is an infectious-inflammatory consequence of biliary obstruction. Increased intra-biliary pressure above 30 cm H2O (normal 10–15) is associated with complete bile stasis and induces cholangiovenous reflux. This results in translocation of organisms and an inflammatory response that can result in death if not properly treated. Cholangitis may “ascend” from an obstruction arising in the extra-hepatic biliary tree with the two common causes of extra-hepatic biliary obstruction being common bile duct stones and pancreatic (or periampullary) carcinoma. Choledo- cholithiasis is more common as a primary cause of cholangitis, whereas the endo- scopic treatment of periampullary carcinomas is the commonest cause of iatrogenic cholangitis. During the first decade of laparoscopic gallbladder surgery the inci- dence of acquired biliary strictures increased tenfold and was frequently associated with cholangitis as the presenting manifestation.Typical of cholangitis arising from choledocholithiasis is the prior history of “fluctuant” jaundice – an awareness of having been jaundiced at various times in the past.This is in contrast to patients who present with progressive (or crescendo) jaundice typical of periampullary tumors. The patient may also admit to having had gallstones diagnosed in the past or may have had a prior cholecystectomy. What Are the Risks? It is always a good idea to know who is likely to die from a disease, and why, before you decide how to proceed from the emergency room (ER), through the hospital, and occasionally to the morgue! As with any acute illness, age, associated cardio-respiratory compromise caused by the current event, and the patient’s prior medical problems, all contribute to his or her risk of dying from acute cholangitis. It is always useful to run an APACHE II baseline in the ER and keep a mental note 174 Gary Gecelter of the changes as you monitor your patient to ensure that your interventions, or lack thereof, are not causing a rise in your patient’s score (p. 57). As a rule in this condition, the direct bilirubin decreases as the treatment takes effect. How to Make the Diagnosis? (> Fig. 20.1) Charcot’s Triad (Jean Martin Charcot of Paris,1825–1893) characterizes acute ascending cholangitis: Right upper quadrant (RUQ) pain Fever Jaundice The fever and jaundice are easy to determine.It is our experience that residents miss the objective distinction between the clinical finding of a tender liver, which is the cause of the RUQ pain in cholangitis, and Murphy’s Sign, which is a sign of gallbladder obstruction. Murphy’s Sign (John Benjamin Murphy of Chicago, 1857–1916) is elicited by the presence of point tenderness in the region of the distended gallbladder fundus as it descends, on deep inspiration, to the awaiting fingertips of the right hand.The RUQ tenderness seen in acute cholangitis is objec- tive percussion tenderness elicited along the width of the liver, especially in the epigastrium where the left lobe is not shielded by the costal margin. In addition, Fig. 20.1. “Oh, the urine is dark … what do you call that, triad? – Charcoal triad?” 20 Acute Cholangitis 175 there is usually a varying degree of liver swelling, which makes this sign easier to elicit. If correctly identified in the ER “cot-side”, the treatment for cholangitis is begun before obtaining any investigations. What are Signs of Complications? In the elderly patient, or when medical intervention is delayed, the syndrome can progress to include two further clinical features: Confusion (do not assume that any elderly-confused patient has senile dementia, ask about the patient’s baseline mental status) “Septic” shock These two, when added to the Charcot’s Triad become the Reynold’s Pentad (B. M. Reynolds, USA), which is associated with a 4-fold mortality risk increase; consequently, clinical decision intervals must be hourly rather than q4h! Special Investigations Ascending cholangitis is diagnosed on the aforementioned clinical grounds. With early presentation,the jaundice may only be biochemical and must be substan- tiated by a liver panel. A typical panel has mildly elevated transaminases, variably elevated total bilirubin with a direct preponderance, and a disproportionately elevated alkaline phosphatase and glutamyl transferase; white cells are usually elevated. Amylase may be mildly elevated (less than 5-fold elevation) but don’t be confused by acute pancreatitis (> Chap. 18). Note, however, that patients with gall- stone pancreatitis may have an associated element of ascending cholangitis. Other laboratory data will be appropriate for the patient’s degree of hydration and re- spiratory status, which can deteriorate rapidly if the patient presents late or the diagnosis is delayed. The right upper quadrant sonogram is the best test to confirm the diagnosis. Invariably gallstones are seen in the gallbladder (unless the patient has had a prior cholecystectomy).Mild intra-hepatic ductal dilatation will be demonstrated and the common hepatic duct /common bile duct axis will be variably dilated above a normal level of 7 mm. Rarely can the incriminating bile duct stone(s) be seen directly. Rather, their presence is inferred from the above associated findings. If gallstones are not seen in the gallbladder then the diagnosis of (malignant) peri- ampullary biliary obstruction must be suspected justifying the performance of a thin slice pancreas protocol CT scan. This is usually requested after treatment is begun and during regular hours to prevent a substandard nocturnal study. 176 Gary Gecelter Treatment Initial Management Antibiotics. Initial management comprises appropriate empiric antibiotics with bowel rest and rehydration. Although it has always been felt that antibiotic selection should be based upon the drug’s ability to concentrate in the biliary system, recent re-evaluation of this concept has concluded that no antibiotics are able to reach obstructed bile and that the spectrum of suspected pathogens is a better target for antimicrobial selection. Coverage must be directed against Gram-negative, gut- derived organisms (typically E. coli and Klebsiella sp.). Up to a fifth of bile cultures will grow anaerobic organisms such as Bacteroides or Clostridia sp., so it is a good idea to include appropriate coverage empirically. ERCP (endoscopic retrograde cholangiopancreatography). It is important to recognize that most patients will defervesce within 24 hours on the above treat- ment, allowing interventional therapies to be scheduled electively and selectively. A minority of patients will have persistent fever and pain, and their bilirubin may rise, implying a persistent complete obstruction. It is at this time that urgent ERCP is indicated with sphincterotomy and stone extraction. It is the gastroenterologist’s task to ensure biliary decompression at the first attempt. This does not mean com- plete duct clearance, as stones may be difficult to extract at one session, but it may mean that placement of a plastic biliary stent or nasobiliary tube is necessary. The latter’s advantage is that it can be removed without re-endoscopy after cholecyst- ectomy. If ERCP fails in the critically ill cholangitis patient there is another non- operative alternative – ultrasound-guided percutaneous drainage of the obstructed ductal system by the radiologist. Check it out. Surgical Strategies If the patient is one of the majority who settles with initial conservative meas- ures, then one can elect to perform one of the following semi-elective procedures, based upon one’s local expertise: Preoperative ERCP with common duct clearance, followed by laparoscopic cholecystectomy. ERCP with common duct clearance alone leaving the gallbladder in situ.This is indicated in the very high-risk patient; on follow-up most patients so treated never require a cholecystectomy. Laparoscopic cholecystectomy with laparoscopic common bile duct explora- tion. Open cholecystectomy with common bile duct exploration. 20 Acute Cholangitis 177 In most hospitals preoperative ERCP is selected because it is ubiquitously available. Further, it is diagnostic if periampullary carcinoma is suspected and delineates the biliary anatomy for the surgeon. If it is unsuccessful and the papilla cannot be cannulated then the surgeon knows preoperatively that clearance of the biliary tree at operation must be assured (or the duct bypassed). Primary Emergency Surgical Treatment We have encountered another subset of patients who present with rapid clinical deterioration and may even develop diffuse signs suggesting gallbladder perforation. It is this group which probably benefits from expeditious surgery following resuscitation. The case is made more compelling if they have had a prior gastrectomy that prevents rapid cannulation for ERCP.Staged surgery, comprising initial placement of a T-tube and subsequent elective cholecystectomy once the patient has settled, is a safe option to remember in this situation. Conclusions Acute cholangitis is best managed by a concordant multidisciplinary team that understands when appropriate interventions are needed. Since the introduction of endoscopic management of bile duct stones, surgery is seldom required as an emergency. Removal of the gallbladder and clearance of the bile duct of all stones are the two goals of treatment. In the absence of stones, suspect periampullary carcinoma.When the patient is toxic and ERCP fails,or is not immediately available, do not procrastinate, waiting for “re-ERCP tomorrow” – operate and drain the obstructed biliary system! In ascending cholangitis consider the common bile duct an abscess..