lunes, 10 de junio de 2019

Managing Acute Cholangitis

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By Dr. Liji Thomas, MDReviewed by Hannah Simmons, M.Sc.

Acute cholangitis is diagnosed on the basis of the clinical features, supported by laboratory evidence of systemic infection. Imaging is helpful in revealing biliary obstruction and any underlying causes.

Necessary laboratory tests include a complete blood count, ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), renal and liver function tests to guide antibiotic dosage, prothrombin time and INR. An early blood culture is indicated to detect bacteremia or septicemia. According to the TG13 guidelines, bile should be sampled during biliary drainage for bile culture, which is positive for organisms in almost 60% to 90% of cases.

Management of acute cholangitis is based upon early resuscitation with appropriate fluids and antibiotics. Subsequently, biliary drainage is carried out with the definitive treatment of the underlying cause.

Tokyo Guidelines

Tokyo guidelines introduce the concept of bundled care in biliary obstruction and acute cholangitis. A bundle comprises a chosen set of healthcare elements based on evidence-based practice. These must be put into practice as a group as in such a situation they lead to a better outcome than that which is possible when one or a few of the elements are implemented in isolation.

If the diagnosis of acute cholangitis is suspected, the patient must be assessed every 6-12 hours by TG18 criteria until a diagnosis is confirmed. The investigation begins with an ultrasound scan of the abdomen, followed by a CT (computerized tomography), MRI (magnetic resonance imaging), MRCP (magnetic resonance cholangiopancreatography) and HIDA scan as appropriate.

The severity of acute cholangitis must be assessed repeatedly following the initial diagnosis, at intervals less than 24 hours, up to 48 hours after diagnosis.

Initial Treatment

Treatment is initiated with adequate fluid and electrolyte therapy, with analgesics as required and antibiotics at full-strength.

For grade I or mild illness, biliary drainage is carried out failing response to initial treatment.

For grade II and grade III (moderate and severe disease), it is simultaneously performed with initial treatment, or if that is not possible, the patient should probably be transferred to another facility. Supportive care is important in addition, for severe disease, and includes vasopressors and ventilatory care.

Once the acute stage is over, the cause of the cholangitis is treated. The procedure for biliary drainage is selected depending on the severity of the symptoms, and timed accordingly. Several drainage techniques are available, such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and open surgical drainage.

ERCP is vital in relieving the biliary tract obstruction of acute cholangitis. If this fails or is not feasible, PTC, endoscopic biliary drainage under ultrasound guidance is considered.

Biliary drainage may also be done using endoscopic nasobiliary drainage (ENBD) by nasobiliary catheter, percutaneous transhepatic biliary drainage (PTBD), EUS-guided drainage and open surgical drainage (T-tube drainage after laparotomy).

ENBD has the advantages of allowing thick pus to be drained better, washing out of the tube in case of clogging, and repeated cholangiography in case the biliary stricture is not localized. It also makes biliary aspirate available for culture without requiring sphincterotomy. It is, however, uncomfortable, and may be dislodged by a careless or disoriented patient.

PTBD is indicated if ERCP fails, or if it is not feasible due to a poor risk patient. Some contraindications include ascites, clotting disorders and intrahepatic obstruction. It is uncomfortable, can cause biliary peritonitis or intraperitoneal bleeding, and sepsis.

During biliary drainage, stent placement is performed, with sphincterotomy if required. Surgical drainage is resorted to if other techniques are contraindicated or if they fail but has a mortality of 20% to 60%. Currently, choledochotomy with T-tube drainage is performed, avoiding choledocholithotomy, to shorten the surgery. Stone extraction by laparoscopic choledochotomy may be done if endoscopic extraction fails to remove a stone in the common bile duct. If cholecystolithiasis (gallbladder stones) are responsible, the gallbladder must be removed after the acute stage.