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ACUTE CHOLECYSTITIS AND ACUTE CHOLANGITIS

DIAGNOSIS AND TREATMENT GUIDELINES


Soetamto Wibowo
Department of Surgery Dr. Soetomo General Hospital Airlangga University Surabaya
Abstract
Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and
gallbladder. Acute biliary infection is a systemic infectious disease which requires prompt
treatment and has a significant mortality rate. Charcots triad was first proposed in the
characteristic findings of acute cholangitis (*), and Murphys sign was proposed as a
diagnostis method for acute cholecystitis (**). Many new technologies have been
developed for the management of acute biliary infection.
The Tokyo Guidelines formulate clinical guidance for health care providers regarding the
diagnosis severity assessment, and treatment of acute cholangitis and acute cholecystitis
(3).
We also discuss our experience with patients suffering acute cholangitis.
* Jean Martin Charcot (1877)
** Murphy JR. (1903)
ACUTE CHOLECYSTITIS
Acute cholecystitis is initiated by gall stone, which obstructs the gallbladder outlet. Each
year 1 2 % of asymptomatic gallbladder stone develop serious symptom or
complication. Acute cholecystitis occurs in approximately 10 % to 20 % of patients with
symptomatic gallbladder stone (1). In acute cholecystitis the pain and right 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, thickened wall, mucosal separation (double larger), peri cholecystics, fluid
collection or intramural air (table 1) (fig. 1) (2).
Tab. 1 Diagnostic criteria for acute cholecystitis
A
B
C

Local signs of inflammation


(1) Murphys signs, (2) RUQ, mass / pain / tenderness
Systemic signs of inflammation
(1) Fever, (2) elevated CRP, (3) elevated WBC count > 3 mg / dl
Imaging findings of acute cholecystitis

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 Murphys 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)
Severity assessment criteria of acute cholecystitis.
Tokyo Guidelines Classify the severity of acute cholecystitis into three categories : Mild
(grade I), Moderate (grade II) and Severe (grade III) (table 2)
Tab. 2 : Categories of Acute Cholecystitis
Mild (grade I)
Moderate (grade II)

Severe

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 upper abdominal quadrant (3) duration > 72 hours (4)
marked local inflammation
Acute cholecystitis is accompanied by one or more organ
dysfunction : (1) Cardiovascular (hypotension) (2) 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. In difficult case,


percutaneous gallbladder drainage is recommended, then
elective cholecystectomy can be performed after improvement

Severity of acute
cholagitisSevere
(grade III)
Acute Cholecystitis

Appropriate organ support in addition to medical


treatment. Management of severe local inflammation by
percutaneous gallbladder drainage and
/ or
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 and parenteral antibiotics followed by early surgery if 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
(tab 5) (9).

Tab 5 : Likelihood Ratio and Prevalence Ratio of preoperative indicators of


common bile duct stone 2005 2006

Clinical Variable
Cholangitis
Jaundice
Acute pancreatitis
Laboratory Variable
Bilirubin > 2 mg / dl
Alkaline ph. (> 250 u/l)
Gamma GT (> 9 u/l)
GOT / GPT (> 100 u/l)
Sonographic Variable
CBD > 10 mm

Pos. Likelihood
Ratio

Neg. Likelihood
Ratio

Prevalence
Ratio

10.07
8.45
1.86

0.16
0.08
0.90

10.71 (p<0.000)
8.52 (p<0.000)
1.97 (p=0.448)

5.8
6.0
4.9
7.15

0.40
0.20
0.17
0.24

5.9 (p<0.000)
5.6 (p<0.000)
4.9 (p<0.000)
7.2 (p<0.000)

12.6

0.46

12.73 (p< 0.000)

Our data suggested that acute cholangitis and dilated CBD were the most significant risk
for choledocholithiasis (9)
The current study demonstrated three level of risk for CBD stones in patients with
choledocholithiasis (fig. 6) (8)

Clinical Presentation
Clinical diagnosis

Ultrasound
Serum
biochemistries

Choledocholithiasis

Cholecystitis
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

Risk Of CBD

LC with IOC

LC with IOC

LC with IOC

93%

32%

4%

LC

1%

Fig. 6 : Diagnostic and Therapeutic Algorithm for the management of


Patients undergoing laparoscopic cholecystectomy (8)
Digit in paracentesis was adjusted (18)

The management strategy chosen will depend on personal experience, equipment


availability, time and the availability of other departmental expertise.
There is no concensus into the ideal approach (6, 17).

References
1. Nakeeb A, Ahrendt SA, Pitt HA, Calculous Biliary Disease on Greenfields
surgery ed. Mulholland MN, Lippincott William and Wilkins 4th ed 2006, pg. 978
999
2. Hirda M, Takada T, Kawarada Y et al, Diagnostic Criteria and severity assessment
of acute cholecystitis : Tokyo Guidelines, J. Hepatobiliary Pancreat. Surg. 2007;
14 : 78 82.
3. Mayumi T, takada T, Kawarada Y et al, Result of the Tokyo Concensus Meeting,
Tokyo Guidelines, J. Hepato Biliary Pancreat. Surg. 2007; 14 : 114 121.
4. Wada K, Takada T, Kawarada T et al, Diagnostic Criteria and Severity assessment
of acute cholangitis, Tokyo Guidelines, J.hepato Bilairy Pancreat Surg. 2007; 14 :
52 58.
5. Miura F, Takada T, Kawarada Y et al, Flowwchart for the diagnosis and treatment
of acute cholangitis and cholecystitis, Tokyo Guidelines, J. Hepato Biliary
Pancreat. Surg. 2007; 14 : 27 34.
6. Dandan IS, Cholodocholithiasis http : www.emedicine.com/med/topic350.htm,
Sept. 21, 2005.
7. Yossoff IA, Barkun JS, Barkun AN, Diagnosis and management of cholecystitis
and cholangitis, Gastroenterol. Cl. NA 2003; 32 : 1154 68.
8. Liu TH, Consorti ET, Kanashima et al : Patients evaluation and management with
selective use of magnetic resonance cholangiography and endoscopic retrograde
cholangio pancreatography before laparoscopy, Ann. Surg 2001; 224 : 33 40.
9. Wibowo S, Choledocholithiasis facts and complication, PIT IKABI XVIII, 9 11
Nov. 2006, Balikpapan.
10. Yasuda H, Takada T, Kawarada Y et al, Unusual cases of acute cholcystitis and
cholangitis, Tokyo Guidelines, J. Hepatobiliary Pancreat surg. 2007; 14 : 98
113.
11. Mosheschein, Acute Cholecystitis, Scheins common sense emergency Abdominal
Surgery, Springer 2nd ed 2005 pg. 163 171.
12. Nagino M, Takada T, Kawarada Y, Methode and timing of biliary drainage for
acute cholangitis, Tokyo Guidelines, J. Hepatobiliary Pancreatic Surgery 2007; 14
: 68 71.
13. Nathanson LK, Shaw IM : Gallstone in Haptobiliary and Pancreatic surgery 3 rd
ed, ed by Garden OJ, Elsevier Saunders 2005; pg. 167 192.
14. Papi C et al . Timing of Cholecystectomy for acute cholecystitis : a meta analysis,
Am J. Gastroenterol 2004; 99 : 147 155.

15. Weber S, Cholecystitis in Surgery of the Liver Biliary Tract anf Pancreas 4 th ed.
by Blumgart L.H., saunders Elsevier 2007 pg. 482 7.
16. Johansson M. et al, management of acute cholecystitis in the laparoscopic era,
results of prospective reandomized clinical trial, J. Gastrointestinal surg. 2003; 7 :
642 5.
17. Blumgart LH, Stones in the common bile duct Clinical Features and open
surgical approaches and techniques in Surgery of the Liver Biliary Tract and
Pancreas 4th ed. ed. by Blumgart LH, Saunders Elsevier 2007 pg. 528 47.
18. Kim KH, Kim W, Lee HI, Prediction of common bile duct stones : Its validation
in laparoscopic cholecystectomy, Hepato Gastroenterology; 1997; 44 : 1574 9.

(grade III)
(grade I)
Timing of Surgery
The optimal interval of time between the diagnosis of acute cholangitis and
definitive treatment with cholecystectomy has been the subject of prospective
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 (11).
In problematic situations such as fibrotic triangle of Calot consider to do a partial or
subtotal cholecystectomy.
It is better to remove 95% of the gallbladder (i.e. subtotal cholecystectomy) than
101% (i.e. together with a piece of the bile duct).

Fig. 3 : Flowchart for the management of Acute Cholecystitis


Complications od Acute Cholecystitis
Several complications of acute cholecystitis are recognized in clinical practice. These
include empyema of the gallbladder, emphysematous cholecystitis, perforation and
cholecyst enteric fistula. All of these complications need prompt surgical
intervention.

Unusual Cases

Acute acalculous cholecystitis account for 2% - 15% of cases is caused by


disturbed micro circulation in critically ill patients and is therefore life
threatening condition. The treatment is the same as that for calculous
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)
Emergency surgery for acute cholecystitis in elderly patients
(recommendation C).

ACUTE CHOLANGITIS
The pathogenesis of acute cholangitis is biliary infection associated 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 of the diagnostic criteria of acute cholangitis are as follows :


(4)

(1) Charcots triad is a definite diagnostic criteria for acute cholangitis. Inspite
of the fact the presentation of Charcots triad variable in 50% to 70% of
patients (6,7).
(2) If a patient does not have all the components of Charcots triad, the definite
diagnosis can be achieved if both an inflammatory respons and biliary
obstruction are demonstrated by the laboratory data (blood test) and
imaging findings.
(3)

(4) Tab 3 (4) Shows the diagnostic criteria for acute cholangitis
(5)
(6) Tab 3 : Diagnostic criteria for acute cholangitis (4)
(7)
(8) A. Clinical data
1. History of biliary disease
(9)
2. Fever and chills
(10)
3. Jaundice
(11)
4. Upper abdominal pain
(12)
B. Laboratory data 5. Evidence of inflammatory respons
(13)
6. Abnormal liver function test
(14)
C. Imaging
7. Biliary dilatation or evidence of an etiology
(15)
(stricture, stone, stent etc.)
(16)
(17)
(18)
(19)
(20)
SEVERITY ASSESSMENT
(21)
(22)
Organ dysfunction is the most common predictor of poor outcome and
as classified as severe cholangitis (grade III).
(23)
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 to medical treatment are classified as having mild cholangitis
(grade I) (tab. 4)(4).
(24)
(25)
Tab 4 : Criteria for severity assessment of acute cholangitis (4)
(26)
(27)
Criteria