1. Cholangitis &
Management of
Choledocholithiasis
Ruby Wang MS 3
Surg 300A
8/20/07

2. Content
 Case
 Cholangitis
 Clinical manifestations
 Diagnosis
 Treatment
 Diagnosis and management of choledocholithiasis
 Pre-operative
 Intra-operative
 Post-operative

3. Case
 HPI:
 86 yo lady p/w 3-4 episodes of RUQ/mid-epigastric
abdominal pain over the last year, lasting generally several
hours, accompanied by occasional emesis, anorexia, and
sensation of shaking chills.
 ROS: negative otherwise
 PE:
 VS: T 36.2, P98 , RR 18, BP 124/64
 Abdominal exam significant for RUQ TTP
 Labs
 AST 553, ALT 418. Alk Phos 466. Bilirubin 2.7
 WBC 30.3
 Imaging
 Abdominal US: multiple gallstones, no pericholecystic fluid,
no extrahepatic/intrahepatic/CBD dilatation

4. Introduction
 Cholangitis is bacterial infection superimposed on biliary obstruction
 First described by Jean-Martin Charcot in 1850s as a serious and
life-threatening illness
 Causes
 Choledocholithiasis
 Obstructive tumors
 Pancreatic cancer
 Cholangiocarcinoma
 Ampullary cancer
 Porta hepatis
 Others
 Strictures/stenosis
 ERCP
 Sclerosing cholangitis
 AIDS
 Ascaris lumbricoides

5. Epidemiology
 Nationality
 U.S: uncommon, and occurs in association with biliary obstruction and causes of
bactibilia (s/p ERCP)
 Internationally:
 Oriental cholangiohepatitis endemic in SE Asia- recurrent pyogenic
cholangitis with intrahepatic/extrahepatic stones in 70-80%
 Gallstones highest in N European descent, Hispanic populations, Native
Americans
 Intestinal parasites common in Asia
 Sex
 Gallstones more common in
women
 M: F ratio equal in
cholangitis
 Age
 Median age between 50-60
 Elderly patients more likely
to progress from
asymptomatic gallstones to
cholangitis without colic

6. Pathogenesis
 Normally, bile is sterile due to constant flush,
bacteriostatic bile salts, secretory IgA, and biliary
mucous; Sphincter of Oddi forms effective barrier to
duodenal reflux and ascending infection
 ERCP or biliary stent insertion can disrupt the Sphincter
of Oddi barrier mechanism, causing pathogeneic
bacteria to enter the sterile biliary system.
 Obstruction from stone or tumor increases intrabiliary
pressure
 High pressure diminishes host antibacterial defense-
IgA production, bile flow- causing immune dysfunction,
increasing small bowel bacterial colonization.
Adam.about.com
 Bacteria gain access to biliary tree by retrograde ascent
 Biliary obstruction (stone or stricture) causes bactibilia
 E Coli (25-50%)
 Klebsiella (15-20%),
 Enterobacter (5-10%)
 High pressure pushes infection into biliary canaliculi,
hepatic vein, and perihepatic lymphatics, favoring
migration into systemic circulation- bacteremia
(20-40%). Gpnotebook.co.uk Pathology.med.edu

7. Clinical Manifestations
 RUQ pain (65%) Charcot’s
 Fever (90%) Triad:
Found in Reynold’s
 May be absent in elderly patients 50-70% Pentad:
 Jaundice (60%) of
patients
 Hypotension (30%)
 Altered mental status (10%)
Additional History
Pruitus, acholic stools
PMH for gallstones, CBD stones,
Recent ERCP, cholangiogram
Additional Physical
Tachycardia
Mild hepatomegaly

8. Diagnosis: lab values
 CBC
 79% of patients have WBC > 10,000, with mean of 13,600
 Septic patients may be neutropenic
 Metabolic panel
 Low calcium if pancreatitis
 88-100% have hyperbilirubinemia
 78% have increased alkaline phosphatase
 AST and ALT are mildly elevated
 Aminotransferase can reach 1000U/L- microabscess formation in the
liver
 GGT most sensitive marker of choledocholithiasis
 Amylase/Lipase
 Involvement of lower CBD may cause 3-4x elevated amylase
 Blood cultures
 20-30% of blood cultures are positive

9. Diagnosis: first-line imaging
Ultrasonography
 Advantage:
 Sensitive for intrahepatic/extrahepatic/CBD dilatation
 CBD diameter > 6 mm on US associated with high
prevalence of choledocholithaisis
 Of cholangitis patients, dilated CBD found in 64%,
 Rapid at bedside
 Can image aorta, pancreas, liver
 Identify complications: perforation, empyema, abscess
 Disadvantage
 Not useful for choledocholithiasis:
 Of cholangitis patients, CBD stones observed in 13%
 10-20% falsely negative - normal U/S does not r/o cholangitis
Med.virgina.edu
 acute obstruction when there is no time to dilate
 Small stones in bile duct in 10-20% of cases
CT
 Advantages
 CT cholangiograhy enhances CBD stones and increases detection
of biliary pathology
 Sensitivity for CBD stones is 95%
 Can image other pathologies: ampullary tumors, pericholecystic
fluid, liver abscess
 Can visualize other pathologies- cholangitis: diverticuliits,
pyelonephritis, mesenteric ischemia, ruptured appendix
 Disadvantages
 Sensitivity to contrast
 Poor imaging of gallstones Soto et al. J. Roenterology. 2000

10. Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
 Advantage
 Detects choledocholithiasis, neoplasms, strictures, biliary dilations
 Sensitivity of 81-100%, specificity of 92-100% of
choledocholithiasis
 Minimally invasive- avoid invasive procedure in 50% of patients
 Disadvantage:
 cannot sample bile, test cytology, remove stone
 Contraindications: pacemaker, implants, prosthetic valves
 Indications
 If cholangitis not severe, and risk of ERCP high, MRCP useful
 If Charcot’s triad present, therapeutic ERCP with drainage should
not be delayed.
Endoscopic retrograde cholangiopancreatography (ERCP)
 Gold standard for diagnosis of CBD stones, pancreatitis, tumors,
sphincter of Oddi dysfunction
 Advantage
 Therapeutic option when CBD stone identified
 Stone retrieval and sphincterotomy
 Disadvantage
 Complications: pancreatitis, cholangitis, perforation of duodenum
or bile duct, bleeding
 Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

11. Medical Treatment
 Resucitate, Monitor, Stabilize if patient unstable
 Consider cholangitis in all patients with sepsis
 Antibiotics
 Empiric broad-spectrum Abx after blood cultures drawn
 Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)
 Carbapenems: gram negative, enterococcus, anaerobes
 Levofloxacin (250-500mgIV qD) for impaired renal fxn.
- 80% of patients can be managed conservatively 12-24 hrs Abx
- If fail medical therapy, mortality rate 100% without surgical
decompression: ERCP or open
- Indication: persistent pain, hypotension, fever, mental confusion

12. Surgical treatment
 Endoscopic biliary drainage
 Endoscopic sphincterotomy with stone
extraction and stent insertion
 CBD stones removed in 90-95% of
cases
 Therapeutic mortality 4.7% and
morbidity 10%, lower than surgical
decompression
 Surgery
 Emergency surgery replaced by non-
operative biliary drainage
 Once acute cholangitis controlled, surgical
exploration of CBD for difficult stone removal
 Elective surgery: low M & M compared with
emergency survey
 If emergent surgery, choledochotomy carries
lower M&M compared with cholecystectomy
with CBD exploration

13. Our case…
 Condition:
 No acute distress, reasonably soft abdomen
 ERCP attempted
 Duct unable to cannulate due to presence of duodenum diverticulum
at site of ampulla of Vater
 Laparoscopic cholecystectomy planned
 Dissection of triangle of Calot
 Cystic duct and artery visualized and dissected
 Cystic duct ductotomy
 Insertion of cholangiogram catheter advanced and contrast bolused
into cystic duct for IOC
 Intraoperative cholangiogram
 Several common duct filling defects consistent with stones
 Decision to proceed with CBD exploration

14. Choledocholithiasis
 Choledocholithiasis develops
in 10-20% of patients with
gallbladder disease
 At least 3-10% of patients
undergoing cholecystectomy
will have CBD stones
 Pre-op
 Intra-op
 Post-op

15. Pre-op diagnosis & management
 Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP
 High risk (>50%) of choledocholithiasis:
 clinical jaundice, cholangitis,
 CBD dilation or choledocholithiasis on ultrasound
 Tbili > 3 mg/dL correlates to 50-70% of CBD stone
 Moderate risk (10-50%):
 h/o pancreatitis, jaundice correlates to CBD stone in 15%
 elevated preop bili and AP,
 multiple small gallstones on U/S
 Low risk (<5%):
 large gallstones on U/S
 no h/o jaundice or pancreatitis,
 normal LFTs
 Treatment:
 ERCP
 Surgery

16. Intra-op diagnosis and management
 Diagnosis: intraoperative cholangiography (IOC)
 Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and
common hepatic duct diameter, presence or absence of filling defects.
 Detect CBD stones
 Potentially identify bile duct abnormalities, including iatrogenic injuries
 Sensitivity 98%, specificity 94%
 Morbidity and mortality low
 Treatment
 Open CBD exploration
 Most surgeons prefer less invasive techniques
 Laparoscopic CBD exploration
 via choledochotomy: CBD dilatation > 6mm
 via cystic duct (66-82.5%)
 CBD clearance rate 97%
 Morbidity rate 9.5%
 Stones impacted at Sphincter of Oddi most difficult to extract
 Intraoperative ERCP

17. Early years: Open CBD exploration &
Introduction of endoscopic sphincterotomy
 1889, 1st CBD exploration by Ludwig
Courvoisier, a Swiss surgeon
 Kocherization of duodenum and short
longitudinal choledochotomy
 Stones removed with palpation, irrigation
with flexible catheters, forceps,
 Completion with T-tube drainage
 For many years, this was the standard
treatment for cholecystocholedocholithiasis
 1970s, endoscopic sphincterotomy (ES)
 Gained wide acceptance as good, less
invasive, effective alternative
 In patients with CBD stones who have
previously undergone cholecystectomy, ES
is the method of choice

18. Open surgery vs Endoscopic sphincterotomy
 In patients with intact gallbladders, ES or open choledochotomy?
 Design: 237 patients with CBD stone and intact gallbladders, 66% managed with ES and rest
with open choledochotomy
 Results: No significant difference in morbidity and mortality rates
 Lower incidence of retained stones after open choledochotomy
 Conclusion: open surgery superior to ES in those with intact gallbladders
 Miller et al. Ann Surg 1988; 207: 135-41
 Is ES followed by open CCY superior to open CCY+ CBDE?
 Results: Initial stone clearance higher with open surgery (88% vs 65%, p< 0.05)
 Conclusion: routine preoperative ES not indicated
 Stain et al. Ann Surg 1991; 213: 627-34
 Cochraine database of systematic reviews
 Design: 8 trials randomized 760 patients comparing ERCP with open surgical clearance
 Results: Open surgery more successful in CBD stone clearance, associated with lower
mortality
 Conclusion: open bile duct surgery superior to ES
 Cochrane database of systematic reviews 2007
 In patients with severe cholangitis, open or ES?
 Study design: Randomized, prospsective trial of 82 patients with choledocholithiasis and
severe toxic cholangitis managed endoscopically or with open choledochotomy
 Results: In group managed initially with endoscopic drainage, need for ventilatory support
(29% vs 63%) and mortality (33% vs 66%) significantly less
 Conclusion: toxic cholangitis should managed with endoscopic sphincterotomy
 Lai et al. J Engl J Med 1992; 326: 1582-6

19. Laparoscopic CBD Exploration
 In 1989, laparoscopic removal of gallbladder replaced open surgery
 In the past decade, laparoscopic CBD exploration (LCBDE) developed
 Techniques
 IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones
 Choledochotomy
 If cystic duct < CBD stone, If CBD > 6mm
 If stone located proximal to cystic duct-common bile duct junction
 If stone impacted in bile duct or papilla
 Transcystic approach
 If CBD < 6mm in diameter
 Cystic duct dissected close to junction with CBD, transverse incision made
 Guidewire into CBd through cholangiogram catheter under fluoroscopy
 Osotonic NaCl irrigate CBD to flush small stones through sphincter of Oddi
 Unsuccessful in 10-20% of patients
 Contraindications: pancreatitis, sphincter anomalies,
 Results
 High rate of lap CBD clearance: 73-100%
 Similar success rates between transcystic and choledochotomy
 Conversion to open 5.2-19.6%
 Causes : multiple/impacted stones, bleeding, unclear anatomy,equipment failure
 Length of hospital stay shorter in LCBDE than ES
 Mortality and Morbidity
 No difference between LCBDE and ES
Cochrane database of systematic reviews 2007

20. Post-op Diagnosis and
Management
 T-tube cholangiography
 T-tube placed following CBDE to diagnosis and
manage retained stones
 Retained CBD stones in 2-10% of patients after
CBD exploration
 If not obstruction, tube is clamped and left for 6
weeks.
 Cholangiogram repeat after 6 wks
 ERCP
 Treatment of retained stones undetected or left
behind

21. In summary
 Non-surgical care first line
 Goal: extract stone, but if not possible, drain bile to improve condition until
definitive surgical intervention
 ERCP: both diagnostic and therapeutic
 Stones> 1cm - Sphincterotomy needed before extraction
 Stones > 2cm: require lithotripsy or chemical dissolution
 PTC
 Surgical Care if endoscopy and IR drainage fail
 Issues
 Exploration of CBD
 Fate of gallbladder
 CBD exploration: laparoscopy first line
 Transcystic:
 Choledochotomy
 CBD exploration: open
 If laparoscopy has failed or contraindicated
 T-tube cholangiogram 10-14 days posto
 Open CBD is safe option, but limited to setting of concomitant open surgery

22. …our case
 Open procedure
 Due to previous failure of ERCP due to duodenum diverticulum
 Incision joining epigastric port with subcostal inciion
 Dis
 Cholecystectomy
 Gallbladder was dissected free from liver bed
 Cystic artery/duct identified, ligated.
 CBD exploration
 2 suture splaced in direction of common duct through anterior wall in the
same longitudinal direction
 Choledochotomy- extended in both proximal and distal directions of
CBD
 4 CBD stones evacuated
 Catheter advanced within CBD to perform sphincterotomy
 T-tube placed within common bile duct.