Recurrent pyogenic cholangitis


Recurrent pyogenic cholangitis

Description, Causes and Risk Factors:

Recurrent pyogenic cholangitis is a disease of the intrahepatic biliary system, characterized by intrahepatic pigment stones, strictures, and dilation of the intrahepatic biliary tree, and recurrent cholangitis.

Recurrent pyogenic cholangitis is a complex hepatobiliary disease known by various synonyms. Recurrent pyogenic cholangitis is characterized by recurrent attacks of abdominal pain, fever, and jaundice caused by intrahepatic ductal strictures and calculi. Repeated medical and surgical treatments are frequently required in patients with recurrent pyogenic cholangitis. The therapeutic goal for the management of recurrent pyogenic cholangitis should include the complete clearance of calculi and debris from the biliary tract and the elimination of bile stasis to prevent recurrent attacks of the disease. Therefore, for effective treatment, accurate topographic evaluation of the distribution of the disease is required prior to surgical intervention.

Recurrent pyogenic cholangitis is common in Southeast Asia, but it is being increasingly encountered in the West as a result of growing Asian immigration. It may affect both intra and extrahepatic biliary tree. Left lobe is more commonly affected and bilateral involvement occurs in about 30% cases. The prevalence of recurrent pyogenic cholangitis has more than doubled since 1983. Recurrent pyogenic cholangitis affects males and females equally, in a younger age group (between 20 and 40 years of age), and there is a predilection for the lower socioeconomic classes.

The pathogenesis of this condition is poorly understood. Although, recurrent pyogenic cholangitis and recurrent cholangitis are associated with clonorchis sinensis and Ascaris lumbricoides infections, evidence for these infections is absent in most of the cases. Bile cultures are almost always positive and usually yield Escherichia coli [E. coli], Enterococcus faecalis, or other enteric bacteria, but Clonorchis or Ascaris parasites or ova are recovered from the stool in only 25% of cases. Recurrent pyogenic cholangitis involves the common bile duct [CBC] and left hepatic lobe in 31% of cases, CBD and both lobes of the liver in 31% of cases. It is confined to the CBD in 27%, and only rarely confined to the right lobe. The gallbladder is usually disease-free. The primary pathologic changes of recurrent pyogenic cholangitis are proliferative fibrosis of bile ductal walls, with inflammatory infiltration of the portal tracts, calculi, and periductal abscesses. Bile-pigmented calculi can lead to progressive biliary obstruction and recurrent infection that result in the formation of multiple cholangitic hepatic abscesses, biliary strictures, and eventually severe hepatic destruction, cirrhosis and portal hypertension.

Recurrent pyogenic cholangitis should be suspected in anyone with a history of recurrent right upper quadrant pain despite past cholecystectomy. Its diagnosis and treatment require the cooperation of surgeon, endoscopist, and diagnostic and interventional radiologists. Surgical interventions still carry a high morbidity and must be tailored to the individual patient, depending on the severity of disease.

Symptoms:

Signs and symptoms:

    Abdominal pain.

  • Fever.

  • Portal hypertension.

  • Acute cholangitis.

  • Acute pancreatitis.

  • Jaundice.

  • Hepatomegaly.

  • Strictures may be found anywhere in the biliary tree, but are more common in the main stem of the hepatic ducts, especially the left, and in the intrahepatic ducts.

  • Bilirubinate stones.

  • Biliary cirrhosis and liver failure are possible complications.

Diagnosis:

Useful imaging modalities include ultrasound, CT scan, ERCP (endoscopic retrograde cholangiopancreatography), and MRCP (magnetic resonance cholangiopancreatography).

Ultrasound is an important component of the patient's initial evaluation as it is an excellent screening tool for the presence of dilated bile ducts (intrahepatic and extrahepatic) and intraductal stones. But, sonography is not a perfect imaging modality since it is operator-dependent and has some limitations in its ability to evaluate obstructed bile ducts in this clinical setting. Abdominal CT scan is an important imaging study that compliments sonography. CT scans more completely demonstrate the full extent of the disease, including the presence of pneumatosis, hepatic parenchymal atrophy, liver abscesses, and bilomas. Invasive cholangiography, be it endoscopic or percutaneous, was once the most accurate way to define biliary ductal anatomy, providing visualization of strictures, stones, and ductal ectasia. But, it has some limitations especially in the face of high grade stenoses, impacted stones or complete ductal obstruction. Magnetic resonance cholangiopancreatography (MRCP) has recently been purported as an excellent tool for depicting the biliopancreatic tree. MRCP is a noninvasive imaging technique that does not require the administration of intravenous or intraductal contrast, yet allows direct visualization of the biliopancreatic system similar to conventional cholangiography. Some authors argue that MRCP should replace invasive procedures like ERCP in those patients needing a cholangiographic evaluation without therapeutic intervention.

Treatment:

The therapeutic goals for the management of recurrent pyogenic cholangitis should include the complete clearance of calculi and particulate debris from the biliary tract and the elimination of bile stasis to prevent recurrent stone formation. It requires multidisciplinary approach, integrating Interventional Radiology, Interventional Endoscopy & Surgery. Acutely, recurrent pyogenic cholangitis is treated with broad spectrum antibiotics and ERCP decompression. CBD exploration and T-tube drainage are reserved for failure of medical management. Further attacks can be prevented by elective CBD exploration with choledochoscopy for stone retrieval, hepatic resection or biliary-enteric bypass procedure with access loop fixed to the abdominal wall. Complete clearance of stones is sometimes impossible because of the presence of huge number of stones or because many more stones are discovered only on postoperative cholangiogram. Postoperatively, stone extraction or stricture dilatation can be achieved via cutaneous stoma (access loop), T-tube tract or percutaneous transhepatic biliary drain tract. With numerous sessions of choledochoscopy, aided by electrohydraulic lithotripsy, complete stone clearance can be achieved in 90% of cases. Hepatic resection should be reserved for patients with significant hepatic atrophy (as in our patient) and fibrosis, multiple liver abscesses or concurrent intrahepatic cholangiocarcinoma, which may occur in 3%-5% of patients treated conservatively and hepatic resection carries no apparent additional morbidity or mortality compared to CBD exploration and stone clearance alone.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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