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ACUTE CHOLECYSTITIS Acute cholecystitis is initiated by gall stone, which obstructs the gallbladder outlet. Each year year 1 – 2 % of asym asympt ptom omat atic ic gall gallbl blad adde derr ston stonee deve develo lop p seri seriou ouss symp sympto tom m or complication. Acute cholecystitis occurs in approximately 10 % to 20 % of patients with symptom symptomati aticc gallbl gallbladd adder er stone stone (1). (1). In acute acute cholecy cholecysti stitis tis the pain pain and right right upper upper quadrant abdominal symptoms may persist more than 6 hours and is accompanied by local peritonitis and systemic evidence of inflammation. The ultrasonography findings include a distended gallbladder stone or sludge containing gallbladder, gallbladder, thickened thickened wall, mucosal separation separation (double (double larger), larger), peri cholecysti cholecystics, cs, fluid fluid collection or intramural air (table 1) (fig. 1) (2). Tab. 1 Diagnostic criteria criteria for acute cholecystitis A B C
Local signs of inflammation (1) Murphy’s signs, (2) RUQ, mass / pain / tenderness Systemic si signs of inflammation (1) Fever, (2) elevated CRP, (3) elevated WBC count > 3 mg / dl Imaging fi findin dings of of ac acute ch cholecys cystitis
One item in A and one in B – definite diagnosis C confirms the diagnosis Imaging findings of acute cholecystitis Ultrasonography findings (level 4) (fig. 1) Sonography Murphy’s sign Thickened (gallbladder wall (> 4 mm) Enlarged gallbladder ( > 8 cm x 4 cm) Incarcerated gallbladder, debris echo, peri cholecystic fluid collection Sonolucent layer in the gallbladder wall (double larger) Striated intramural lucencies, and Doppler Signal. MRI – CT scan (level 3 b) (fig. 2) Tc – HIDA scans (level 4) Tab. 2 : Categories of Acute Cholecystitis
“Mild” (grade I)
“Moderate” (grade II)
No findings of organ dysfunction. No criteria for “moderate” or “severe” acute cholecystitis 1) elevated WBC (>18.000/mm3) (2) palpable tenderness in the right right upper upper abdomi abdominal nal quadran quadrantt (3) duration duration > 72 hours hours (4) marked local inflammation
“Severe”
Acut Acutee chole cholecy cyst stit itis is is accom accompan panie ied d by one or more more orga organ n dysfunction : (1) Cardiovascular (hypotension) (hypotension) (2) Neurological Neurological (decrease consciousness) (3) Respiratory (Pa O2) Fi O2 ratio < 300) (4) Renal oliguria, creatinine > 2.0 mg/dl) (5) Hepatic (PT – INR > 1.5) (6) Hematological (platelet count < 100.000 / mm3)
Flowchart for the management of acute cholecystitis (fig 3) (3) “Mild” (grade I) Acute cholecystitis
Early laparoscopic cholecystectomy is the preferred treatment or elective cholecystectomy
“Moderate” (grade II) Acute Cholecystitis
Early laparoscopic or open cholecystectomy. ch olecystectomy. In difficult case, percutaneous gallbladder drainage is recommended, then elective cholecystectomy can be performed after improvement
Appr Approp opri riat atee orga organ n supp suppor ortt in addi additi tion on to medi medica call Severity of acute cholagitis“Severe” treatmen treatment. t. Managem Management ent of severe severe local local inflamma inflammatio tion n by (grade III) percutaneous gallbladder drainage and / or Acute Cholecystitis cholecystectomy if needed. Mild Moderate (grade II)Severity Onset of organ dysfunctionNoNoYesResponse to initial medical treatmentYesNoNo Treatment of acute Cholangitis
The treatment of acute cholangitis should be guided by the grade of severity of the disease. Initial management of acute cholangitis comprise appropriate empiric antibiotic (Chepalosporin III + Metronidazol) with bowel rest and rehydration. (fig 5) (3, 5)
Fig. 5 : Flowchart for the management of acute cholangitis (5)
Emergent drainage is essential for severe cases whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment (12). Biliary drainage is the treatment of choice for moderate or severe acute cholangitis in elderly patients (recommendation C)(12) How do we select the mode of biliary drainage (12) : Endoscopic biliary drainage, either nasobiliary drainage or biliary stent placement • (recommendation A) Percutaneous transhepatic biliary drainage (recommendation B) • Acute cholangitis resulting from CBD stone traditionally was managed by supportive measures measures and parenteral antibiotics antibiotics followed by early surgery if improvement improvement was slow or absent (5, 17) Cholecystectomy is indicated after the resolution of acute cholangitis (recommendation B) (12). Choledocholithiasis is most common as primary cause of cholangitis (1, 5, 6, 8, 9, 11) In our series of 151 consecutive patients with gallbladder stone in Surabaya from January 2005 until August 2006 we analyzed 14 patients (9.27%) with common bile duct stone. Our data suggested that acute cholangitis and dilated CBD were the most significant risk for choledocholithiasis
The current study demonstrated three level of risk for CBD stones in patients with choledocholithiasis Clinical Presentation Clin Clinic ical al dia diagn gnos osis is
Ultrasound
Serum biochemistries
Chol Choled edoc ocho holi lith thia iasi siss
Chol Cholec ecys ysti titi tiss Pancreatitis Resolving choledocholithiasis
Cholecystitis Pancreatitis Resolving Choledocholitiais
Biliary colic
CBD ≥ 5 mm (10 mm)
CBD ≥ 5 mm (10 mm)
CBD < 5 mm (10 mm)
CBD < 5 mm (10 mm)
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
T Bili < 1.5 (2) Alk. Phos < 150 (250 AST < 100 ALT < 100
Therapeutic ERCP
MRC
CBD stones No CBD stones Therapeutic ERCP
LC with IOC
LC with IOC
LC with IOC
LC
(grade III) (grade I) Timing of Surgery The optima optimall inter interva vall of time time betwe between en the diagno diagnosis sis of acute acute cholan cholangit gitis is and definiti definitive ve treatme treatment nt with cholecy cholecystec stectom tomy y has bee been n the subject subject of prospec prospective tive randomized trials. Early laparoscopic cholecystectomy (tipically defined as < 3 days) seems to be the preferred surgical technique for patients with acute cholecystitis ( 5, 11, 14, 15). Patients experienced no increased perioperative morbidity or mortality and had a shorter length of hospital stay ( 14, 15, 16). When the gallbladder is “difficult” : “Go fundus first (dome down) and stay near the gallbladder wall”. In problematic situations such as fibrotic triangle of Calot consider to do a partial or subtotal cholec cholecyst ystec ecto tomy. my. “It is bette betterr to remov removee 95% 95% of the gallbl gallblad adder der (i.e. (i.e. subto subtotal tal cholecystectomy) than 101% (i.e. together with a piece of the bile duct)”.
Complications od Acute Cholecystitis Several complications of acute cholecystitis are recognized in clinical practice. These include empyema of the gallbladder, emphysematous cholecystitis, perforation and chol cholec ecys ystt ente enteri ricc fist fistul ula. a. All All of thes thesee comp compli lica cati tion onss need need prom prompt pt surg surgic ical al intervention. Unusual Cases •
•
•
•
Acute acalculous cholecystitis account for 2% - 15% of cases is caused by disturb disturbed ed micro micro circulat circulation ion in critical critically ly ill patients patients and is the therefo refore re life threa thr eate tenin ning g cond conditi ition. on. Th Thee trea treatme tment nt is the same same as that that for calcu calculou louss cholecystitis. Abdominal echo and CT scan are useful in the diagnosis of acute acalculous cholecystitis. Percutaneous Transhepatic gallbladder drainage is the treatment of choice for the elderly with acute cholecystitis who are diagnosed as inoperable due to a high surgical risk (recommendation C) Emergen gency surg urgery for for acute chol holecyst ystitis itis in elde lderly pati atients nts (recommendation C).
• • •
ACUTE CHOLANGITIS
• •
The pathoge pathogenesi nesiss of acute acute cholang cholangitis itis is biliary biliary infectio infection n associa associated ted with partial or complete obstruction of the biliary system. Obstruction raises the intra ductal pressure in the bile duct to levels high enough (> 200 mmH2O)
to cause cholangio venous or cholangio lymphatic reflux (normal pressure : 100 mmH2O – 150 mmH2O) (fig. 4) (1) • •
• • •
Fig. 4 : Pathophysiology of acute cholangitis (1)
• •
Basic concepts concepts of the diagnostic diagnostic criteria of acute cholangit cholangitis is are as follows : (4)
•
(1) Charcot’s Charcot’s triad is a definite definite diagnostic criteria criteria for acute acute cholangitis. cholangitis. Inspite of the fact the presentation of Charcot’s triad variable in 50% to 70% of patients (6,7). (2) If a patient does does not have have all the components components of Charcot’s Charcot’s triad, triad, the definite definite diagnosis can be achieved if both an “inflammatory respons” and “biliary obstruct obstruction” ion” are demonst demonstrate rated d by the laboratory laboratory data (blood test) test) and imaging findings. (3) (4) Tab 3 : Diagnostic criteria for acute cholangitis (4) (5) (6) (6) A. Cli Clin nica ical dat data a 1. Hi Histo story of of bi biliar iary dis diseease ase (7) 2. Fever and chills (8) 3. Jaundice (9) 4. Upper abdominal pain (10) B. La Laboratory da data 5. Ev Evidence of of in infla flammatory re respons (11) 6. Abnormal liver function test (12) C. Imaging 7. Biliary dilatation or evidence of an etiology (13) (13) (str (stric ictu ture re,, ston stone, e, sten stentt etc. etc.)) (14) (15) (16) SEVERITY ASSESSMENT
(17) (18 (18) Organ dys dysfunc functtion ion is the the mos most com common mon pre predict ictor of of poo poor out outcome and as classified as “severe cholangitis (grade III). (19) Patient with acute cholangitis that is not complicated by organ dysfunction, who did not respond to medical treatment and who continue to have SIRS are classified as “moderate” cholangitis (grade II). Patients who respond respond to medica medicall treatme treatment nt are classifie classified d as having having “mild” “mild” cholangi cholangitis tis (grade I) (tab. 4)(4). (20) Tab 4 : Criteria for severity assessment of acute cholangitis (4) (21) (22) (23) Criteria
Local signs of inflammation (1) Murphy’s signs, (2) RUQ, mass / pain / tenderness Systemic si signs of inflammation (1) Fever, (2) elevated CRP, (3) elevated WBC count > 3 mg / dl Imaging fi findin dings of of ac acute ch cholecys cystitis
One item in A and one in B – definite diagnosis C confirms the diagnosis Imaging findings of acute cholecystitis Ultrasonography findings (level 4) (fig. 1) Sonography Murphy’s sign Thickened (gallbladder wall (> 4 mm) Enlarged gallbladder ( > 8 cm x 4 cm) Incarcerated gallbladder, debris echo, peri cholecystic fluid collection Sonolucent layer in the gallbladder wall (double larger) Striated intramural lucencies, and Doppler Signal. MRI – CT scan (level 3 b) (fig. 2) Tc – HIDA scans (level 4) Tab. 2 : Categories of Acute Cholecystitis
“Mild” (grade I)
“Moderate” (grade II)
No findings of organ dysfunction. No criteria for “moderate” or “severe” acute cholecystitis 1) elevated WBC (>18.000/mm3) (2) palpable tenderness in the right right upper upper abdomi abdominal nal quadran quadrantt (3) duration duration > 72 hours hours (4) marked local inflammation
“Severe”
Acut Acutee chole cholecy cyst stit itis is is accom accompan panie ied d by one or more more orga organ n dysfunction : (1) Cardiovascular (hypotension) (hypotension) (2) Neurological Neurological (decrease consciousness) (3) Respiratory (Pa O2) Fi O2 ratio < 300) (4) Renal oliguria, creatinine > 2.0 mg/dl) (5) Hepatic (PT – INR > 1.5) (6) Hematological (platelet count < 100.000 / mm3)
Flowchart for the management of acute cholecystitis (fig 3) (3) “Mild” (grade I) Acute cholecystitis
Early laparoscopic cholecystectomy is the preferred treatment or elective cholecystectomy
“Moderate” (grade II) Acute Cholecystitis
Early laparoscopic or open cholecystectomy. ch olecystectomy. In difficult case, percutaneous gallbladder drainage is recommended, then elective cholecystectomy can be performed after improvement
Appr Approp opri riat atee orga organ n supp suppor ortt in addi additi tion on to medi medica call Severity of acute cholagitis“Severe” treatmen treatment. t. Managem Management ent of severe severe local local inflamma inflammatio tion n by (grade III) percutaneous gallbladder drainage and / or Acute Cholecystitis cholecystectomy if needed. Mild Moderate (grade II)Severity Onset of organ dysfunctionNoNoYesResponse to initial medical treatmentYesNoNo Treatment of acute Cholangitis
The treatment of acute cholangitis should be guided by the grade of severity of the disease. Initial management of acute cholangitis comprise appropriate empiric antibiotic (Chepalosporin III + Metronidazol) with bowel rest and rehydration. (fig 5) (3, 5)
Fig. 5 : Flowchart for the management of acute cholangitis (5)
Emergent drainage is essential for severe cases whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment (12). Biliary drainage is the treatment of choice for moderate or severe acute cholangitis in elderly patients (recommendation C)(12) How do we select the mode of biliary drainage (12) : Endoscopic biliary drainage, either nasobiliary drainage or biliary stent placement • (recommendation A) Percutaneous transhepatic biliary drainage (recommendation B) • Acute cholangitis resulting from CBD stone traditionally was managed by supportive measures measures and parenteral antibiotics antibiotics followed by early surgery if improvement improvement was slow or absent (5, 17) Cholecystectomy is indicated after the resolution of acute cholangitis (recommendation B) (12). Choledocholithiasis is most common as primary cause of cholangitis (1, 5, 6, 8, 9, 11) In our series of 151 consecutive patients with gallbladder stone in Surabaya from January 2005 until August 2006 we analyzed 14 patients (9.27%) with common bile duct stone. Our data suggested that acute cholangitis and dilated CBD were the most significant risk for choledocholithiasis
The current study demonstrated three level of risk for CBD stones in patients with choledocholithiasis Clinical Presentation Clin Clinic ical al dia diagn gnos osis is
Ultrasound
Serum biochemistries
Chol Choled edoc ocho holi lith thia iasi siss
Chol Cholec ecys ysti titi tiss Pancreatitis Resolving choledocholithiasis
Cholecystitis Pancreatitis Resolving Choledocholitiais
Biliary colic
CBD ≥ 5 mm (10 mm)
CBD ≥ 5 mm (10 mm)
CBD < 5 mm (10 mm)
CBD < 5 mm (10 mm)
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
At least 2 of : T Bili ≥ 1.5 (2) Alk. Phos ≥ 150 (250 AST ≥ 100 ALT ≥ 100
T Bili < 1.5 (2) Alk. Phos < 150 (250 AST < 100 ALT < 100
Therapeutic ERCP
MRC
CBD stones No CBD stones Therapeutic ERCP
LC with IOC
LC with IOC
LC with IOC
LC
(grade III) (grade I) Timing of Surgery The optima optimall inter interva vall of time time betwe between en the diagno diagnosis sis of acute acute cholan cholangit gitis is and definiti definitive ve treatme treatment nt with cholecy cholecystec stectom tomy y has bee been n the subject subject of prospec prospective tive randomized trials. Early laparoscopic cholecystectomy (tipically defined as < 3 days) seems to be the preferred surgical technique for patients with acute cholecystitis ( 5, 11, 14, 15). Patients experienced no increased perioperative morbidity or mortality and had a shorter length of hospital stay ( 14, 15, 16). When the gallbladder is “difficult” : “Go fundus first (dome down) and stay near the gallbladder wall”. In problematic situations such as fibrotic triangle of Calot consider to do a partial or subtotal cholec cholecyst ystec ecto tomy. my. “It is bette betterr to remov removee 95% 95% of the gallbl gallblad adder der (i.e. (i.e. subto subtotal tal cholecystectomy) than 101% (i.e. together with a piece of the bile duct)”.
Complications od Acute Cholecystitis Several complications of acute cholecystitis are recognized in clinical practice. These include empyema of the gallbladder, emphysematous cholecystitis, perforation and chol cholec ecys ystt ente enteri ricc fist fistul ula. a. All All of thes thesee comp compli lica cati tion onss need need prom prompt pt surg surgic ical al intervention. Unusual Cases •
•
•
•
Acute acalculous cholecystitis account for 2% - 15% of cases is caused by disturb disturbed ed micro micro circulat circulation ion in critical critically ly ill patients patients and is the therefo refore re life threa thr eate tenin ning g cond conditi ition. on. Th Thee trea treatme tment nt is the same same as that that for calcu calculou louss cholecystitis. Abdominal echo and CT scan are useful in the diagnosis of acute acalculous cholecystitis. Percutaneous Transhepatic gallbladder drainage is the treatment of choice for the elderly with acute cholecystitis who are diagnosed as inoperable due to a high surgical risk (recommendation C) Emergen gency surg urgery for for acute chol holecyst ystitis itis in elde lderly pati atients nts (recommendation C).
• • •
ACUTE CHOLANGITIS
• •
The pathoge pathogenesi nesiss of acute acute cholang cholangitis itis is biliary biliary infectio infection n associa associated ted with partial or complete obstruction of the biliary system. Obstruction raises the intra ductal pressure in the bile duct to levels high enough (> 200 mmH2O)
to cause cholangio venous or cholangio lymphatic reflux (normal pressure : 100 mmH2O – 150 mmH2O) (fig. 4) (1) • •
• • •
Fig. 4 : Pathophysiology of acute cholangitis (1)
• •
Basic concepts concepts of the diagnostic diagnostic criteria of acute cholangit cholangitis is are as follows : (4)
•
(1) Charcot’s Charcot’s triad is a definite definite diagnostic criteria criteria for acute acute cholangitis. cholangitis. Inspite of the fact the presentation of Charcot’s triad variable in 50% to 70% of patients (6,7). (2) If a patient does does not have have all the components components of Charcot’s Charcot’s triad, triad, the definite definite diagnosis can be achieved if both an “inflammatory respons” and “biliary obstruct obstruction” ion” are demonst demonstrate rated d by the laboratory laboratory data (blood test) test) and imaging findings. (3) (4) Tab 3 : Diagnostic criteria for acute cholangitis (4) (5) (6) (6) A. Cli Clin nica ical dat data a 1. Hi Histo story of of bi biliar iary dis diseease ase (7) 2. Fever and chills (8) 3. Jaundice (9) 4. Upper abdominal pain (10) B. La Laboratory da data 5. Ev Evidence of of in infla flammatory re respons (11) 6. Abnormal liver function test (12) C. Imaging 7. Biliary dilatation or evidence of an etiology (13) (13) (str (stric ictu ture re,, ston stone, e, sten stentt etc. etc.)) (14) (15) (16) SEVERITY ASSESSMENT
(17) (18 (18) Organ dys dysfunc functtion ion is the the mos most com common mon pre predict ictor of of poo poor out outcome and as classified as “severe cholangitis (grade III). (19) Patient with acute cholangitis that is not complicated by organ dysfunction, who did not respond to medical treatment and who continue to have SIRS are classified as “moderate” cholangitis (grade II). Patients who respond respond to medica medicall treatme treatment nt are classifie classified d as having having “mild” “mild” cholangi cholangitis tis (grade I) (tab. 4)(4). (20) Tab 4 : Criteria for severity assessment of acute cholangitis (4) (21) (22) (23) Criteria
