Now, let’s move on to discuss cholangitis. Cholangitis results from an obstruction of biliary drainage
in the common bile duct. As a result, the gallstones that migrate either from the gallbladder
or de novo primary common bile duct stones create an obstruction leading to secondary infection
of the bile system. Cholangitis is classically described in terms of physical findings as Charcot's triad.
This includes right upper quadrant abdominal pain, fevers, and jaundice. I think this bears repeating.
Right upper quadrant pain, fevers, and jaundice makes up the Charcot’s triad. What findings
might be indicative of cholangitis? Again, your chemistries may be quite normal. Your white blood cell
count may be elevated. But unlike symptomatic cholelithiasis, your total bilirubin may be elevated
because there is a common bile duct obstruction. Similarly, alkaline phosphatase may also be elevated
as may be AST and ALT due to congestion. Let’s take the Charcot’s triad one step further
into Reynolds' pentad. Again, fever, jaundice, right upper quadrant abdominal pain,
coupled with hypotension, and confusion is significant for a patient who has clinical deterioration
as a result of cholangitis. This poses a surgical emergency. What are some common findings of cholangitis?
Again, the patient may present with symptoms and signs very similar to acute cholecystitis such as
the Murphy sign to remind you it’s an arrest of inspiration with deep palpation of the right upper quadrant.
When one obtains an ultrasound, one can see gallstones or common bile duct stone with dilation.
Measurement of the common bile duct is very, very important. Although there is no specific rule
dictating how large of a common bile duct is considered large, generally speaking, one gets 1 mm
diameter of common bile duct per decade of life. In terms of laboratory findings, liver function tests
may be abnormal as previously described. How do we manage cholangitis? In my mind,
the schematic discusses whether or not the patient has any hemodynamic instability.
Does the patient have hypotension? With hypotension, the diagnosis is then biliary sepsis.
Antibiotics are immediately started. The surgical emergency requires emergent drainage
of the common bile duct so that the bile has appropriate drainage. This doesn’t necessarily mean surgery
but the common bile duct can be drained via percutaneous techniques. Remember, if you’re presented
with this scenario and the patient presents with cholangitis and has hemodynamic instability,
the appropriate action or the next management is not further workup, rather it is to do emergent
drainage of the common bile duct, most likely percutaneously. Now, what about the patient
with cholangitis that does not have any hypotension? In those patients, antibiotics are started.
We still want to drain the common bile duct but it’s no longer necessarily the emergency situation
that a patient who’s hemodynamically unstable with pain. This is endoscopic retrograde
cholangiopancreatography commonly known as an ERCP. With the patient sedated or intubated,
an endoscopy especially designed for an ERCP is passed through the stomach, the duodenum
into the papilla through the sphincter of Oddi. In this direction, contrast can be injected
through the common bile duct system, not only potentially diagnostic for obstruction
but maybe therapeutic. During these procedures particularly for common bile duct obstruction,
it’s fairly routine to perform a sphincterotomy where the sphincter of Oddi is incised.
This would allow easier passage of any stones in the common bile duct. During this procedure,
GI doctors will insert multiple instruments into the common bile duct to clear of stones.
This is an image of a percutaneous transhepatic cholangiogram. Notice that the ERCP instrument
is no longer in place. This is because the technique of a percutaneous transhepatic cholangiogram
is done in the right upper quadrant of the abdomen through the liver into the biliary system.
This is also potentially diagnostic and therapeutic. A drain is usually left in place after this procedure
to allow proper drainage of the bile. What if percutaneous or ERCP methods fail? The patient still
requires appropriate drainage. That’s where surgeons come into play. Here is the image
of high definition of intraoperative common bile duct exploration. This can be performed in open
or laparoscopic fashion. The most important thing for you to remember is if percutaneous methods fail,
the next management is to continue until the common bile duct is drained of bile. In this situation,
the common bile duct will be incised. Stones will be released. A T tube or Silastic tube will be left in place
and brought exteriorized through the right upper quadrant of the abdomen to allow bile drainage
until the common bile duct has healed. Some important clinical pearls to remember:
It is very important to recognize cholangitis early to facilitate expedient management which usually
requires drainage of the biliary system. You must have a high index of suspicion in diabetic patients
for more serious gallbladder infection. In diabetic patients or patients on steroids, they are more likely
to present with gangrene as cholecystitis if not on antibiotics or have surgery in a timely fashion.
For your examination, remember, if the physical examination or the ultrasound shows equivocal findings
for cholecystitis, your next step in management should be to obtain a HIDA scan to confirm.
With the HIDA scan, you’re looking for a cystic duct obstruction or non-filling of the gallbladder.
Thank you very much for joining me on our discussion of gallstones.