CHOLANGITIS

1. CHOLANGITIS R .Sarath Menon

2. ACUTE ( Bacterial) Suppurative Non Suppurative • Sclerosing Cholangitis

3. ACUTE CHOLANGITIS

4. Definition • Inflammation of the bile ducts • Bacterial infection

5. History • By Jean-Martin Charcot in 1877 • Charcot triad • Reynolds & Dargan – Reynolds pentad

6. Pathophysiology • Biliary tract obstruction • Elevated intraluminal pressure • Infection of bile

7. Etiology • Choledocholithiasis • Malignant Strictures • Benign Strictures • Indwelling Tubes or Stents • Cholangiography • Parasitic • Ischaemia • Chemicals

9. Electron microscope view of a Gall Stone

10. Bacteriology Gram Negative Pathogen • E-coli (25-50%) • Klebsiellae Pneumonia (15-20%) • Enterobacter Species (5-10%) Gram Positive Pathogen • Enterococcus (10-20%)

11. Bacteriology • Bacteria are present on bile culture in approximately 75% patients with acute stage • Patients with common duct stones have a higher probability of positive bile culture than those with gallstones in the gallbladder or cystic duct

12. Bacteriology Some features of bacteria that may enhance pathogenicity in this setting include: • External pili in Gram negative Enterobacteria, which facilitate attachment to foreign surfaces such as a stone or stent. • A glycocalyx matrix composed of exopolysaccharides produced by bacteria which protect the organisms from host defense mechanisms and may hinder penetration of antibiotics.

13. Symptoms • Biliary colic pain: episodic RUQ or epigastric abdominal pain that begins abruptly, is continuous, resolves slowly and lasts for 30 minutes to 3 hrs • Jaundice • Spiking fever with chills • Nausea and vomiting may precipitate by fatty food

14. Symptoms • Charcot’s triad: • Biliary colic pain • Jaundice • Spiking fever with chills • Reynold's pentad • Charcot’s triad + mental confusion + hypotension:often suggested severe septicemia (only present in about 50% cases)

15. Differential Diagnosis • Cholecystitis and Biliary Colic • Diverticular Disease • Hepatitis • Mesenteric Ischemia • Pancreatitis • Shock, Septic

16. Laboratory Data • WBC elevated with neutrophil predominance • A cholestatic pattern of liver function test • Abnormalities with elevations in the serum Alk-P gammaglutamyl transpeptidase (GGT), and bilirubin (predominantly conjugated) concentration. • Serum amylase can be increased to three to four times normal, suggesting an associated pancreatitis.

17. Laboratory Data • Pattern of acute hepatocyte necrosis can be seen in which the aminotransferases may be as high as 1000 IU/L. This pattern reflects microabscess formation in the liver. • Blood cultures should be performed in all patients in whom cholangitis is suspected. • Cultures should also be obtained from bile or stones

18. Investigations 1. Hepatobiliary Ultrasound • initial screen for investgating the possible biliary tract obstruction

20. Indicated for evaluation of hepatic or pancreatic masses 2. Abdominal CT

22. Magnetic resonance cholangiopancreatography Contraindication: Claustrophobia and certain metals (iron) • Excellent sensitivity for biliary duct dilatation, biliary stricture, and intraductal abnormality • Identify pancreatic duct dilatation or stricture, pancreatic duct stenosis

24. V: gall bladder G: Common bile duct P: Pancreatic duct M: stomach D: duodenum

25. Endoscopic retrograde cholangiopancreatogram (ERCP) • Contraindication: Pregnancy, Acute pancreatitis, severe cardiopulmonary disease • Indicated : ---when absence of dilated ducts (Ex; PSC) ---suspected pancreatic, ampullary or gastroduodenal disease ---prior biliary surgery ---For Endoscopic sphincterotomy

26. Endoscopic retrograde cholangiopancreatogram (ERCP) Best visualization of distal biliary tract • Bile or pancreatic cytology • Endoscopic sphincterotomy and stone removal • Biliary manometry

27. Endoscopic retrograde cholangiopancreatogram (ERCP) • Complication of ERCP: • Pancreatitis • Cholangitis, sepsis • Infected pancreatic pseudocyst • Perforation • Hypoxemia, aspiration

31. Percutaneoustranshepatic cholangiogram ( PTCD) Contraindication: Pregnancy, Uncorrectable coagulopathy, massive ascites • Indication: when ERCP is contraindicated or failed ---best visualization of proximal biliary tract --- to get bile cytology, culture and for drainage

34. Treatment • Antibiotic treatment :for nonsuppurative cholangitis • Ampicillin + Gentamicin • Meropenem • Quinolones (Levofloxacin)

35. Treatment • Toxic cholangitis • ICU • Vasopressors • IV Fluids • Antibiotics

36. Treatment • Emergency biliary decompression • Endoscopically • Percutaneous transhepatic

37. Treatment • Proximal Perihilar ObstructionorBiliary – Enteric anastomotic stricture • Percutaneous drainage • Endoscopic • Sphincterotomy • Stone Extraction • Stent

38. Surgical Care • CBD Exploration • T-tube drainage

39. Pyogenic liver abscess Acute renal failure Complications

40. Prognosis • Old age • Female • Acute renal failure • Preexisting cirrhosis • Malignant biliary obstruction

41. Primary Sclerosing Cholangitis • Primary sclerosing cholangitis is a chronic cholestatic disorder characterized by inflammation, fibrosis, and stricturing of medium and large ducts in the intrahepatic and extrahepatic biliary tree • 50-70% of affected individuals are men with mean age of 40 at diagnosis

42. Pathophysiology • Genetic predisposition : B8 or DR3 • Immunulogic causes • Bacterial toxic damage • Viral infection • Smoking behavior • Biliary arteriolar injury

43. Clinical Manifestations • Also, can have fever, chills, nights sweats, RUQ pain • Fatigue and pruritis common presenting symptoms • Most patients asymptomatic at time of diagnosis

44. Laboratory tests • Usually liver tests reveal a cholestatic pattern • Serum Alk phos and BR may fluctuate because of stricture • Serum aminotransferases usually < 300

45. Imaging most important step ERCP and percutaneous transhepatic cholangiography are gold standard MRCP quite reliabe Early in the disease stage, might only see fine or deep ulceration fo the common bile duct Diagnosis

48. Disease related complications • Fatigue and pruritis • Metabolic bone disease • Peristomal Variceal Bleeding • Symptomatic choledocholithiasis • Dominant stricture • Cholangiocarcinoma • Colonic dysplasia and carcinoma

50. TREATMENT • Prednisolone-jaundice • Sx- preop.cholangiography • Stenotic segment exicision & biopsy • Anastomosis • Stents • Liver Transplantation – Only Curative