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Severe
Severity of acute
cholagitisSevere
(grade III)
Acute Cholecystitis
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).
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
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
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%
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).
Unusual Cases
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)
(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