Diagnosis and management of cholecystitis and cholangitis Ian F. Yusoﬀ, MBBS

Transcription

Gastroenterol Clin N Am
32 (2003) 1145–1168
Diagnosis and management of
cholecystitis and cholangitis
Ian F. Yusoff, MBBSa, Jeffrey S. Barkun, MD, MScb,
Alan N. Barkun, MD, MScc,*
a
McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
b
Department of Surgery, Royal Victoria Hospital, McGill University Health Centre,
Montreal, Quebec, Canada H4Y 1S1
c
Division of Gastroenterology, McGill University Health Centre, Montreal General Hospital,
Room D7.148, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
The main biliary tract emergencies are acute cholecystitis, ascending
cholangitis, and acute pancreatitis. These conditions usually arise as
a consequence of calculi obstructing the biliary tree or gallbladder. Less
frequently they may result from benign or malignant strictures of the biliary
tree, biliary tree manipulation, or biliary sludge [1]. Despite therapeutic
advances these conditions still cause significant morbidity and mortality,
particularly in the elderly [2]. This article reviews acute cholecystitis and
cholangitis with a focus on the clinical presentation, diagnosis, and state-ofthe-art management. Acute pancreatitis is dealt with elsewhere in this issue.
Acute calculous cholecystitis (ACC)
Acute cholecystitis is an acute inflammation of the gallbladder. Gallstones are present in over 90% of cases, and cause persistent obstruction of
the gallbladder outlet because of impaction in the neck of the gallbladder,
Hartmann’s pouch, or cystic duct [2,3]. In the remaining 5% to 10% of
cases, gallstones are not identified, so-called ‘‘acalculous cholecystitis’’ [4].
Dr. Yusoff is an Amy and Athelstan Saw Fellow of the Faculty of Medicine and
Dentistry, The University of Western Australia.
Dr. Alan Barkun is a (Chercheur Clinicien Boursier) Senior Research Scholar of the
Fonds de la Recherche en Sante´ du Que´bec.
* Corresponding author.
E-mail address: [email protected] (A.N. Barkun).
0889-8553/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0889-8553(03)00090-6
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I.F. Yusoff et al / Gastroenterol Clin N Am 32 (2003) 1145–1168
Natural history and prevalence of cholelithiasis and cholecystitis
Gallstones are ubiquitous; however, because most patients are asymptomatic, their precise incidence is uncertain. It is estimated that 10% to 15%
of the United States adult population have gallstones [5], and studies from
other westernized societies describe a prevalence of 5% to 20% [6–8]. Only
a minority of patients with gallstones become symptomatic or develops
cholecystitis [9]. The GREPCO investigators estimated the cumulative
probability of developing a complication in patients with asymptomatic
cholelithiasis after 10 years of follow-up was 3% [10] and other studies have
confirmed a low rate of 0.5% to 3% per year of developing complications
[9,11–13]. Once the patient is symptomatic, the rate of biliary complications
rises [9,10,12,13]. The natural history may be less benign in selected
subgroups, such as diabetics and organ transplant recipients [14]. Because
the epidemiology and natural history of gallstones is different in Asian
populations, this discussion is largely limited to Westernized societies [6].
Pathophysiology
The initial event in ACC is believed to be obstruction to gallbladder
drainage [3]. This causes an increase in intraluminal pressure, gallbladder
distention, and wall edema that may progress to venous and lymphatic
obstruction, ischemia, and necrosis. A number of potential mediators have
been identified including cholesterol-supersaturated bile, lysolecithin,
phospholipase A, and prostaglandins [2,3,6]. Enhanced production of
prostaglandins is believed to play a key role in mediating inflammation, and
agents that reduce prostaglandin production have been shown to block the
inflammatory response and reduce the pain of cholecystitis [15,16]. Bile is
sterile in the early stages of acute cholecystitis and infection is believed to be
a secondary event [17,18]. Indeed, although ACC is often considered an
infection, bile cultures are positive only in 20% to 75% of patients [17–19].
The organisms most commonly cultured are enteric bacteria including
Escherichia coli, Klebsiella, and Enterococcus [17–19].
Clinical presentation
Patients with ACC usually present with abdominal pain associated with
fever, nausea, and vomiting. Pain and tenderness are usually localized to the
right upper quadrant and the pain may radiate to the back, right scapula, or
right clavicular area [2,20]. Three quarters of patients with ACC report
a previous attack of biliary colic [21]. The pain is distinguished from biliary
colic by its prolonged duration and the presence of Murphy’s sign (where
mid inspiration is inhibited by pain on palpation of the right upper
quadrant). Singer et al [22] found that a positive Murphy’s sign was highly
sensitive (97%) and predictive (positive predictive value 93%) of ACC.
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Presentation in elderly patients may be atypical. Hafif et al [23] reported that
among 131 patients over 70 years with ACC, right upper quadrant pain was
absent in 27% and fever was absent in 45% [23].
Diagnosis
The combination of prolonged, constant right upper quadrant pain and
tenderness with fever are highly suggestive of ACC. A leukocytosis with
increased neutrophils and band forms is usually present. There may be mild
elevation of the transaminases or bilirubin. A significantly elevated bilirubin
should raise the possibility of choledocholithiasis or Mirrizzi syndrome
(obstruction of the common hepatic duct by a calculus impacted in
Hartmann’s pouch) (Fig. 1) [3,24]. The diagnosis can usually be made by
either ultrasound scanning or biliary scintigraphy. Ultrasonography is
highly sensitive and specific for the presence of gallstones greater than 2 mm,
but does not always confirm the diagnosis of ACC [6,25]. The sonographic
features of ACC include gallbladder wall thickening, pericholecystic fluid,
Fig. 1. Mirrizzi syndrome. Cholangiography showing stone in the gallbladder infundibulum
(solid arrow) compressing externally the proximal common bile duct (open arrow) with resulting
proximal intrahepatic bile duct dilatation.
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gallbladder distention, and a sonographic Murphy’s sign (Fig. 2) [25–27].
The reported test performance of ultrasound varies with sensitivities of 48%
to 100% and specificities of 64% to 100%; the presence of multiple criteria
increases its diagnostic accuracy [26–32]. Biliary scintigraphy is highly
accurate and is the gold standard for the diagnosis of cystic duct
obstruction. Multiple studies have confirmed that scintigraphy has
a sensitivity and specificity for the diagnosis of ACC of over 94% [31–36].
Scintigraphy, however, displays reduced specificity in the presence of hepatic
impairment, parenteral nutrition, or when the patient is in the fasting state
[2]. A positive scan may also be seen in chronic cholecystitis [6]. Scintigraphy
gives little information about nonobstructing cholelithiasis and cannot
detect other pathologic states. In a rigorous meta-analysis, Shea et al [37]
reported that scintigraphy was more sensitive and specific than ultrasonography in ACC, and recommended it be the preferred test in patients with
otherwise equivocal signs of ACC. Nonetheless, the choice of initial imaging
modality remains controversial and varies with institution. The authors’
practice is to use ultrasonography as the screening test for ACC given its
Fig. 2. Cholecystitis. Ultrasonographic study of the gallbladder showing a thickened
gallbladder wall (solid arrows) and pericholecystic fluid (open arrow). Gallstones are seen in
the gallbladder (S ) with the characteristic acoustic shadowing (right brace).
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relatively high accuracy, availability, portability, low cost, quickness, and
ability to detect other pathology. Scintigraphy is usually reserved for cases
where the ultrasound is normal and the clinical suspicion remains high.
Magnetic resonance imaging (MRI) (Fig. 3) and computed tomography
(CT) as an adjunct to ultrasound have been reported as being useful in the
diagnosis of ACC but scanning an acutely ill patient may be difficult and the
added time and expense are infrequently justified [30,38].
Management
The immediate management of ACC includes having the patient fast;
fluid and electrolyte resuscitation; and parental (narcotic) analgesia. If the
patient is vomiting, or if there is evidence of an ileus or gastric distention,
nasogastric tube placement is appropriate [1]. Indomethacin has been
reported to reverse the inflammatory changes in ACC and improve
gallbladder contractility when given early, and diclofenac has been reported
to reduce the rate of progression to ACC in patients with symptomatic
Fig. 3. Cholecystitis. MRI study (heavily T2-weighted) showing a thickened gallbladder wall
(A, solid arrows), sloughed mucosa in the gallbladder lumen (A, open arrow), as well as
pericholecystic fluid (B, open arrow).
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gallstones; however, neither of these agents is used widely for this purpose
[15,16,39]. Intravenous antibiotics are usually commenced empirically when
there are systemic signs (eg, high fever, tachycardia, and hypotension) or if
there has been no improvement over 12 hours with conservative
management [3]. The favorable results of antibiotic treatment that reduces
septic complications seems to depend more on adequate serum rather than
tissue concentrations [30]. The choice of antibiotic varies with local
experience and patterns of bacterial resistance. Single-agent therapy with
an extended spectrum cephalosporin provides safe, appropriate coverage in
most cases; however, in severe or high-risk cases, anaerobe cover is required
(ie, by adding a nitroimidazole) [41,42]. In patients undergoing early
uncomplicated cholecystectomy, prolonging the antibiotic course for more
than 1 day postoperatively has not shown to be of benefit [43]. It must be
emphasized that the optimal therapy in ACC is surgery, not antibiotic
therapy.
Cholecystectomy
Surgical cholecystectomy has been the treatment of choice for ACC since
Langenbuch first described it in 1882. Key issues regard the timing and the
type of surgery and the treatment of those unfit for surgery. Approximately
20% of patients with ACC require emergency surgery because of clinical
deterioration or other features of complicated disease, such as peritonitis or
perforation [2,3]. If the nature of the symptoms is uncertain, exploratory
surgery may be indicated [6]. For the remaining patients, early surgery has
been shown to be superior to delayed surgery. Six randomized controlled
trials before and after the advent of laparoscopic cholecystectomy (LC) have
compared early surgery (within days of admission) with delayed surgery
(performed 6 to 8 weeks after the event) [4–49]. These studies have found
that mortality and complication rates of early cholecystectomy are no
different than for delayed surgery, and that early surgery is preferable
because of reduced total hospitalization costs and morbidity because
approximately 10% to 25% of patients are admitted with recurrent
complications of gallstone disease.
Laparoscopic cholecystectomy has changed the approach to biliary
disease in the last two decades and it has been become the procedure of
choice for elective cholecystectomy. Three randomized controlled trials
[48–50] and multiple nonrandomized trials [51–56] studied the use of LC in
ACC. These trials confirm that early LC is a safe and feasible option
in ACC. Furthermore, these trials suggest LC within 48 to 72 hours of
presentation (early surgery) is preferable to surgery after 3 to 5 days of
conservative therapy (interval surgery) and surgery delayed 6 to 12 weeks
after the attack (delayed surgery). The main reason for this conclusion is
reduced conversion rates in the early surgery group when compared with
the interval surgery group and reduced hospital stay in the early surgery
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group. Indeed, early in the course of ACC inflammation and fibrosis are
limited and tissues planes are easier to find, facilitating laparoscopic
dissection. There may, however, be an increased risk of gallstone spillage
with LC and this may increase the potential risk of subsequent abscess
formation [57].
Percutaneous cholecystostomy
In high-risk patients, where the risks of surgery may outweigh the
benefits, percutaneous cholecystostomy has been reported as an acceptable
option with technical success in most series of over 90% [58–64]. This
procedure can be performed at the bedside under ultrasound control and
gives clinical improvement in 75% to 90% of patients with reported
mortality rates of 5% to 20% (usually related to underlying condition)
[58,59,63,64]. An incomplete or poor response after 48 hours should prompt
a search for alternate sources of sepsis, complications, or tube dislodgment
[3]. Once the patient has recovered, elective cholecystectomy should be
performed [65]. An attempt at elective LC is reasonable in this setting
[64,66,67]. Alternatively, if the patient remains unfit for surgery, percutaneous extraction of the calculi subsequently can be performed under
radiologic or cholecystoscopic guidance [62,68,69]. In selected cases
gallstone dissolution (with methyl tert-butyl ether) and disruption (with
extracorporeal lithotripsy) have been reported [70,71].
Outcomes and complications of ACC
The reported mortality rate of ACC treated with LC is less than 0.5%
with reported morbidity rates of 5% to 20% [48,49,52–55,72–75]. A number
of complications of ACC may occur including gallbladder perforation,
gallbladder gangrene, emphysematous cholecystitis, and empyema. The
presence of any of these calls for urgent surgery. Risk factors for
complications include advanced age; male gender; and associated diseases,
such as diabetes, high temperature, and significant leukocytosis [76].
Gangrenous cholecystitis occurs in 2% to 30% of cases of ACC [3,76].
Perforation of the gallbladder is present in 3% to 10% of patients with ACC
[2]; the most common form of perforation is subacute, with walling off of the
process as a pericholecystic abscess [77]. Free perforation is less common;
occurring usually in institutionalized patients, it presents with general
peritonitis, and has a high mortality rate [77]. Emphysematous cholecystitis
is an uncommon condition occurring when there is secondary infection of
the gallbladder wall with gas-forming organisms. It is most common in
elderly, diabetic men and it is treated with immediate administration of
antibiotics (directed at anaerobes, coliforms, and clostridia species) and
urgent surgery because of the high incidence of free perforation [6]. A
clinical algorithm for the management of ACC is presented in Fig. 4.
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Fig. 4. Clinical algorithm for the management of ACC.
Acute acalculous cholecystitis
Acute acalculous cholecystitis (AAC) is an acute inflammation of the
gallbladder in the absence of demonstrable cholelithiasis [78]. It has been
suggested that a more appropriate name is ‘‘necrotizing cholecystitis’’ to
distinguish it as a distinct entity [79]. AAC accounts for 2% to 12% of
all cases of cholecystitis, and in the United States 5% to 10% of
cholecystectomies are performed for AAC [4,78,80]. AAC most frequently
occurs in those who are critically ill from trauma, sepsis, or burns [4,78,80].
Compared with ACC, AAC tends to have a more complicated course and
a higher morbidity and mortality [80]. Reported mortality rates range from
10% to 50%, in part because of the severity of the underlying disease
[78,80]. Other reported risk factors include vascular disease, male gender,
systemic vasculitides, HIV infection, diabetes mellitus, acute renal failure,
immunosuppression, prolonged fasting, and total parenteral nutrition
[78,80–82]. It has also been reported in patients without identifiable risk
factors [83,84].
Pathophysiology
The pathogenesis of AAC is likely multifactorial with gallbladder stasis,
paresis, and ischemia possibly playing a role [1,78]. Most patients with this
condition have fasted for prolonged periods, are immobile, and often have
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experienced hemodynamic instability, and over 70% may have associated
atherosclerotic disease [82]. It is postulated that concentrated, stagnant bile
and reduced gallbladder perfusion lead to a chemical and ischemic injury to
the gallbladder epithelium [78]. Cholecystectomy specimens from patients
with AAC (but not ACC) demonstrate impaired gallbladder microcirculation suggesting that splanchnic vasoconstriction or intravascular coagulation may be important events [85,86]. As in ACC, infection is thought to be
a secondary event [17].
Clinical presentation and diagnosis
The clinical features of AAC may be the same as ACC; however, some or
all of these features may be absent [87]. Indeed, pyrexia may be the only
symptom, and up to 75% of cases may initially not have symptoms
referable to the right upper quadrant [78]. Diagnostic tests used are those
outlined for ACC. Ultrasound is usually the first line of investigation
because it is widely available, can be performed at the bedside, and can
detect concomitant lesions [3,87]. The sonographic features are similar to
those of ACC, but without calculi [87,88]. Reports of ultrasound sensitivity
have varied from 29% to 92% with specificity being over 90% [80,88,89].
CT is often performed because it is superior to sonography in detecting
other intra-abdominal pathology [90]. The role of hepatobiliary scintigraphy in AAC is debated [78]. It is highly sensitive in diagnosing AAC;
however, it may lack specificity because fasting for prolonged periods may
result in thick, viscous bile and a false-positive scan [4,91]. Morphineaugmented scintigraphy may overcome this shortcoming, and it may
complement sonography in cases where the diagnosis is uncertain [80,89]. In
practice multiple studies may be necessary before the diagnosis becomes
apparent [80,89].
Treatment
Initial supportive management is similar to ACC. Thereafter the
management depends on the patient’s condition. In patients fit for surgery,
open cholecystectomy (OC) has been the traditional approach [2,3,80]. LC
has also been reported as an acceptable alternative in the early stages of
AAC [2,92]. In critically ill patients, cholecystostomy is often preferred.
Percutaneous cholecystostomy has been reported in a number of uncontrolled trials with favorable success rates [93,94]. The catheter may be
left in place for 6 to 8 weeks and if no gallbladder stones are present at
postdrainage cholangiography, the catheter is removed and cholecystectomy
is usually unnecessary. Endoscopic transpapillary gallbladder drainage has
been described for AAC but this technique has few advantages and several
potential disadvantages (including cost and need for sedation) compared
with percutaneous cholecystostomy [95].
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Acute cholangitis
Acute cholangitis occurs as a result of bacterial infection superimposed
on obstruction of the biliary tree. Of the common complications of
gallstones, cholangitis is the most rapidly lethal entity, making accurate
diagnosis and early treatment imperative [6]. Patients who fail conservative
therapy and do not have appropriate drainage have mortality rates
approaching 100% [96–98].
Pathophysiology and etiology
Bile is normally sterile [99]. The sphincter of Oddi, bile flow, and
bacteriostatic properties of bile help maintain this sterility [100]. It is
believed that biliary obstruction reduces antibacterial defenses, causes a state
of immune dysfunction, and increases small bowel bacterial colonization
[98]. Bacteria are able to gain access to the biliary tree; however, the precise
route of infection is uncertain. Ascent from the duodenum or seeding
through the portal vein are the most likely sources, but other possibilities
include spread through the lymphatics or hepatic secretion [98,101]. Once
obstructed bile is colonized, stasis allows for enhanced bacterial multiplication, whereas increased ductal pressure facilitates spread into the
lymphatics and bloodstream [98].
Biliary obstruction is necessary but not sufficient to cause cholangitis [6].
Partial obstruction is associated with a higher rate of infection than complete
obstruction, and obstruction from calculi is associated with a much higher
rate of cholangitis than neoplastic obstruction (which is associated with
cholangitis in about 10% of cases) (Fig. 5) [98,101]. Biliary obstruction after
biliary intervention carries a very high risk of cholangitis [2]. The organisms
most commonly cultured in cholangitis are E coli, Enterococcus, Klebsiella,
Fig. 5. Impacted bile duct stone. Endoscopic image of a patient with acute cholangitis showing
an impacted stone in the ampulla of Vater before (A) and following endoscopic sphincterotomy
(B). (See also Color Plate 17.)
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and Enterobacter [98,102]. Pseudomonas, skin, and oral flora may be found
after biliary interventions and anaerobes are found in up to 15%, most
commonly in elderly patients after biliary surgery [6,100,102]. The most
common cause of cholangitis in the United States is choledocholithiasis
secondary to cholelithiasis with common bile duct stones being found in up to
10% of patients who present with symptomatic gallstones [1,98]. Primary bile
duct stones are unusual in North America but are common in Hong Kong and
Southeast Asia where Oriental cholangiohepatitis is endemic [6]. Less
common causes of cholangitis include obstructing primary tumors of the
ampulla, bile ducts, or pancreas; metastatic tumors to the porta hepatis or
peripancreatic lymph nodes; benign strictures; and primary sclerosing
cholangitis. With increased biliary interventions, postprocedural cholangitis
is becoming more common [2]. Rare causes of cholangitis include obstruction
from hemobilia, parasites, and hereditary abnormalities of the biliary tree
[1,100].
Clinical presentation and diagnosis
Presentation of cholangitis is variable with the classic Charcot’s triad of
fever, right upper quadrant pain, and jaundice present in 50% to 70% of
patients [6,98,103,104]. Fever is usually present in 90% of cases, with jaundice
and abdominal pain present in approximately 60% and 70%, respectively
[98]. A small proportion of patients present with altered mental status (10%
to 20%) and hypotension (approximately 30%) (the so-called ‘‘Reynold’s
pentad’’ when present with Charcot’s triad) [6,98,103,104]. Right upper
quadrant tenderness is present in two thirds of patients but signs of peritoneal
irritation are less common [1]. Severe cholangitis may be associated with
hepatic microabscesses that usually carry a poor prognosis (Fig. 6).
Fig. 6. Hepatic abscesses. Patient with acute cholangitis and a cholangiogram that
demonstrates a multitude of small hepatic abscesses in continuity with the biliary tree.
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The diagnosis of acute cholangitis is often made clinically but laboratory
and imaging confirmation is important to enable distinction from other
conditions, such as acute cholecystitis, hepatic abscesses, and pancreatitis.
Typically, laboratory investigations reveal leukocytosis, hyperbilirubinemia,
elevated alkaline phosphatase, and mild elevation of transaminases
[6,98,103]. Serum amylase may be elevated in up to 30% of patients [1].
Ultrasonography or CT scan are the most commonly used first-line imaging
modalities. Ultrasound is highly sensitive for cholelithiasis [37] but less
sensitive (approximately 50%) for choledocholithiasis [105]. Choledocholithiasis may, however, be inferred if there is associated biliary dilation in
the presence of cholelithiasis. A normal ultrasound does not rule out
cholangitis [6]. Most studies suggest that CT is superior to ultrasonography
for determining the level of biliary obstruction [106–108]. MRI and MR
cholangiopancreatography are accurate for detecting choledocholithiasis
and determining biliary anatomy and specific features of cholangitis have
been described [109], but this test is probably of limited value in acute
cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is
highly accurate for determining the cause of biliary obstruction and allows
appropriate intervention where required. Given its potential for complications and availability of accurate noninvasive imaging ERCP should not be
used solely as a diagnostic modality. Rather, it should be used when the
likelihood of intervention is high, as is often the case in patients with
clinically suspected cholangitis. Indeed, if cholangitis is suspected in
a patient with cholelithiasis and the likelihood of common bile duct stone
is high [100,110,111], the authors believe investigations should be limited (to
blood tests and transabdominal ultrasound) and early referral made for
ERCP.
Treatment
Initial management consists of correction of fluid and electrolyte deficits;
correction of coagulopathy (caused by vitamin K deficiency from prolonged
jaundice or low platelets from sepsis); and analgesia. In all cases of
suspected cholangitis, blood cultures should be obtained and empirical
antibiotics commenced. Although particular agents (eg, fluoroquinolones)
have better biliary penetration, this has not been shown to be of primary
importance in affecting outcome [98]. An aminoglycoside and ampicillin are
no longer the ideal regimen because of emerging gram-negative resistance
and concerns regarding nephrotoxicity [98,112]. Multiple newer regimens
have been shown to be effective, including combination therapy with an
extended-spectrum cephalosporin, metronidazole, and ampicillin; singleagent or combination fluoroquinolones; and ureidopenicillins alone or with
metronidazole [98,113–118]. The choice of agent needs to be guided by local
sensitivities, costs, and the need for anaerobic coverage (eg, in the elderly
and those with biliary manipulation). The authors’ practice is to use a single
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broad-spectrum agent, such as a ureidopenicillin (eg, ticarcillin and
clavulanic acid) where possible. All patients with ascending cholangitis
require biliary drainage. In patients who respond to medical therapy this
may be performed semi-electively during the same admission (and ideally
within 72 hours). Approximately 10% to 15% of patients fail to respond
(within 12 to 24 hours) or deteriorate after initial medical therapy and these
patients need urgent biliary decompression [98,119,120]. Delay in this
situation increases the chance of an adverse outcome [121].
Endoscopic biliary drainage
An ERCP with bile duct drainage or clearance is the treatment of choice
for decompressing the biliary system in acute cholangitis (Fig. 7). It has
a success rate of 90% to 98% and is superior to surgical or percutaneous
drainage in multiple studies [122–127]. Lai et al [124] randomized 83 patients
with acute cholangitis to undergo endoscopic or surgical decompression and
found that mortality (10% versus 32%) was significantly lower in the
endoscopic arm [124]. Other studies have confirmed this [123,126,128].
Fig. 7. Bile duct stones. Patient with acute cholangitis and a cholangiogram that demonstrates
multiple common bile duct stones, and a basket that has been inserted for endoscopic stone
removal (solid arrow).
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ERCP has also been shown to have lower morbidity rates, shorter length of
hospitalization, and a higher definitive success rate than percutaneous
drainage [125,127].
Endoscopic options are biliary drainage with a plastic stent or nasobiliary
catheter or endoscopic sphincterotomy (ES) and bile duct clearance. In the
critically ill or in patients with a coagulopathy, there are concerns that ES
may increase the risk of complications and procedure time [98]. Although
this has never been shown to be the case in clinical trials the concern is
legitimate, especially because biliary drainage without sphincterotomy is
safe and effective in such patients [121,125,127]. In the only randomized trial
directly to compare use of nasobiliary catheter with biliary stent for acute
cholangitis, Lee et al [129] found both to be equally effective but the stent
was associated with less postprocedural discomfort and avoided the
potential inadvertent removal [129]. In patients who are not critically ill,
ES and bile duct clearance should be attempted, and this is the definitive
procedure in patients who have had a cholecystectomy. Complications of
ERCP and ES include pancreatitis, bleeding, stone impaction, and
perforation and occur in 5% to 10%, with bleeding being a particular
problem in those with cholangitis [130]. Antibiotics should be continued
after successful bile duct clearance because patients remain at risk of
developing cholecystitis and empyema [131]. Total duration of antibiotic
therapy depends on response and the authors’ practice is to continue
therapy for 7 days. A Dutch study suggests, however, that in patients with
an uncomplicated course, and good response to biliary drainage, 3 days of
antibiotic therapy may be sufficient [132].
Percutaneous transhepatic biliary drainage
Percutaneous transhepatic biliary drainage can be performed successfully
in up to 90% of patients with biliary tract obstruction [133]. It has higher
rates of morbidity (30% to 80%) and mortality (5% to 15%) than
endoscopic drainage [1,125,133,134]. Nonetheless, percutaneous transhepatic biliary drainage may be preferred over ERCP in specific situations,
such as hepatolithiasis; intrasegmental cholangitis [135]; when the papilla is
inaccessible endoscopically (eg, after Roux-en-Y formation); or when ERCP
has failed. As with ERCP, caution must be taken to correct coagulopathies
preprocedurally.
Surgical biliary drainage
Open surgery has been used to treat cholangitis for almost 100 years. It
is associated with mortality rates of up to 40%, however, and is rarely used
as the first-line method of biliary drainage [103,119,136]. When it is
performed, emergency surgery may be limited to choledochotomy, decompression, and T-tube insertion [98,103,119]. A proportion of patients
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treated endoscopically or percutaneously requires definitive surgical
intervention, and the mortality is low in patients who are able to undergo
this electively [1]. A clinical algorithm for the management of cholangitis is
presented in Fig. 8.
Management of the gallbladder after bile duct clearance
Whether subsequent cholecystectomy is indicated for patients with
cholelithiasis who have had an episode of cholangitis successfully treated
with ES and bile duct clearance is a matter of debate. The rationale for
proceeding to cholecystectomy is to prevent further biliary complications.
Management strategies need to be individualized and guided by risk factors
for surgery and further biliary complication. In retrospective and nonrandomized prospective studies, the risk of patients with common bile duct
stones developing subsequent biliary complications during follow-up has
ranged from 4% to 12% [137–141]. Four randomized controlled trials have
been reported that specifically address this issue [142–145]. Boerma et al
[142] studied 120 patients aged 18 to 80 years with proved symptomatic
common bile duct and concomitant gallbladder stones who underwent ES
and bile duct clearance. Patients were randomized to LC within 6 weeks of
endoscopic stone clearance or to a ‘‘wait and see’’ approach. During a mean
follow-up period of 30 months, 47% of patients in the wait and see group
had recurrent biliary symptoms compared with 2% in the LC group.
Furthermore, 37% of the wait and see group needed cholecystectomy.
Targarona et al [143] randomized 98 elderly and other high-risk patients
with symptoms likely caused by bile duct stones either to ES alone or open
surgery and found that after a mean follow-up of 17 months, biliary
symptoms recurred in 20% of the ES group and 6% of the surgery group.
Hammarstrom et al [144] randomized 83 patients with bile duct stones to ES
and stone removal or open surgery (cholecystectomy and bile duct
exploration) and found that after more than 5 years, 20% of the ES group
underwent cholecystectomy because of recurrent biliary symptoms, whereas
2% of patients in the surgery group had recurrent symptoms from bile duct
stones. During the follow-up period, nonbiliary mortality was significantly
more common in the ES group. Panis et al [145] randomized 206 patients
with common bile duct stones to endoscopic therapy alone or surgery and
found early surgery was required in 19% in the endoscopic group, whereas
only 2% of the surgical group needed reoperation. Taken together these
studies strongly support the recommendation that patients with cholangitis
should undergo elective LC after bile duct clearance if they are fit for
surgery (unless an open approach is known to be required). This may not
apply to Asian patients where bile duct stones may originate from
intrahepatic stones and hence cholecystectomy may not prevent further
biliary complications. Two nonrandomized prospective studies from Hong
Kong have not shown a benefit of cholecystectomy over ES alone in
1160
Fig. 8. Clinical algorithm for the management of ascending cholangitis. *In selected clinical
scenarios PTBD may be preferred to ERCP (see text). ERCP, endoscopic retrograde
cholangiopancreatography; ES, endoscopic sphincterotomy; ESWL, extracorporeal shock
wave lithotripsy; LC, laparoscopic cholecystectomy; PTBD, percutaneous transhepatic biliary
drainage.
1161
preventing recurrent cholangitis or biliary complications in patients with
bile duct stones [139,146]. In contrast a retrospective study from Hong Kong
suggested that patients with bile duct stones treated with ES alone had an
increased risk of recurrent biliary symptoms when compared with those who
also underwent LC and the results of further prospective trials are awaited
[147]. Similarly, a recent randomized trial from Hong Kong showed that,
in patients with cholangitis and gallbladder stones but in the absence of
common bile duct stones, ES resulted in decreased durations of cholangitis
and hospital stay, but no reduced incidence of recurrent acute cholangitis
[148].
Summary
Cholelithiasis is a prevalent condition in Western populations. Most
cases are asymptomatic but complications can occur. Acute cholangitis,
cholecystitis, and gallstone pancreatitis are the most common biliary tract
emergencies and are usually caused by biliary calculi. Whenever possible,
acute cholecystitis should be treated with early LC. AAC is an uncommon
condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the
only required therapy. Endoscopic drainage is the preferred form of biliary
decompression in acute cholangitis and these patients should subsequently
undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between
gastroenterologist, surgeon, and radiologist.
Acknowledgement
The authors thank Dr. Caroline Reinhold and Dr. Ida Khalili for the
MRI images.
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Diagnosis and management of cholecystitis and cholangitis Ian F. Yusoﬀ, MBBS

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