Specific Conditions

Acute Cholangitis

10 Acute cholangitis can be a morbid condition and thus prompt recognition and initiation of treatment

is paramount. Acute cholangitis is defined by bacterial infection of an obstructed biliary ductal system.

Table 61-5 lists the various causes of cholangitis. The most common cause for cholangitis is

choledocholithiasis; however, malignant strictures that have required endoscopic or percutaneous

manipulation are becoming a routine cause of acute cholangitis at tertiary referral centers. The

spectrum of clinical severity can range from a mild self-limited course to a more severe potentially lifethreatening disease characterized by fulminant sepsis with multiorgan dysfunction. The classic triad of

RUQ pain, fever, and jaundice, known as Charcot triad, commonly defines the clinical presentation of

cholangitis. Development of septic shock and mental status changes in this setting is known as Reynolds

pentad.

Acute cholangitis is a clinical diagnosis supported by laboratory and radiographic studies. Elevated

bilirubin, alkaline phosphatase, and transaminase levels in conjunction with a leukocytosis are

commonly present. Radiographic studies will confirm the presence of an abnormal dilated biliary ductal

system.

The management of cholangitis should follow three principles: (1) vigorous resuscitation and

hemodynamic support, (2) broad-spectrum antibiotics, and (3) relief of biliary obstruction (Algorithm

61-2).89 The majority (80%) of patients who present with acute cholangitis will improve with fluid

resuscitation and administration of antibiotics, and therefore CBDE with biliary decompression can be

performed in a more elective and stable environment. Emergent biliary decompression will be required

in 20% of patients who do not respond clinically within 12 to 24 hours of initiation of medical

management or in patients who present with a toxic clinical picture. Biliary decompression can be

achieved either endoscopically or percutaneously. In patients with a perihilar obstruction, strictured

biliary-enteric anastomosis, or nonfunctioning percutaneous biliary drainage catheters are best managed

via the percutaneous route. If the obstruction is within the distal biliary tree then endoscopic biliary

drainage is recommended. This can be accomplished by endoscopic biliary CBDE and stone extraction or

by simple biliary decompression with placement of a plastic biliary stent in unstable patients. In the

setting in which either percutaneous or endoscopic drainage is not possible or available, then surgical

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CBD exploration and biliary drainage with a T-tube is indicated.

Intrahepatic Stones

Intrahepatic stones, or hepatolithiasis, are a form of primary CBD stones that are infrequently

encountered in Western countries and are primarily prevalent in Southeast Asian countries. Intrahepatic

stones are defined as stones present above the confluence of the left and right hepatic ducts. These

stones are primarily brown pigment stones that contain more cholesterol, and less bile acids and

bilirubin than extrahepatic stones. The Japanese have classified intrahepatic stones, as type I for patients

with intrahepatic stones only, type IE for patients with intra- and extrahepatic bile duct stones, type L for

left-sided intrahepatic duct stones, type R for right-sided intrahepatic duct stones, and type C for caudate

stones. Type I stones account for approximately 45% to 50% of intrahepatic stones identified in Asian

countries,90 however in Italy type I stones account for approximately 75% of intrahepatic stones.91

Intrahepatic stones typically occur in the setting of chronic biliary stasis secondary to processes, such as

(i) choledochal cysts, (ii) biliary strictures, and (iii) biliary parasites. Interestingly, the majority (70%)

of patients with intrahepatic stones do not have concomitant gallbladder stones.

Algorithm 61-2. Management of acute cholangitis. (Adapted from Cameron: Current Surgical Therapy. 11th ed. 2014.)

Intrahepatic stones typically present with RUQ or epigastric abdominal pain associated with jaundice

and fever. The previously discussed diagnostic modalities (US, CT, MRCP, and endoscopic and

percutaneous cholangiogram) have similar advantages and disadvantages when evaluating patients with

intrahepatic stones. Ultimately, an endoscopic or percutaneous cholangiogram will be required for

complete evaluation. The percutaneous transhepatic approach with placement of biliary drainage

catheters is preferred since it allows for direct access to the intrahepatic bile ducts for subsequent

therapeutic interventions. With advancements in percutaneous transhepatic techniques, intrahepatic

stones can be managed nonsurgically in many cases using similar endoscopic techniques of stone

extraction or stone lithotripsy mentioned previously; however, surgery also plays a critical role in the

management of intrahepatic stones. If the intrahepatic stone disease is isolated to a single segment or

lobe of liver and is associated with significant parenchymal atrophy or biliary strictures, then hepatic

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resection of this portion of liver should be considered. If stones occur in the setting of a stricture at the

biliary confluence, then a Roux-en-Y hepaticojejunostomy may be warranted.

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Chapter 62

Biliary Injuries and Strictures and Sclerosing

Cholangitis

Chad G. Ball and Keith D. Lillemoe

Key Points

1 Most bile duct injuries or strictures currently occur in association with laparoscopic cholecystectomy,

with an overall incidence of 0.3% to 0.7%.

2 Recognition of a bile duct injury during laparoscopic cholecystectomy is uncommon (<30% of

cases), but if recognized, repair as either an end-to-end duct-to-duct anastomosis in very selected

cases or hepaticojejunostomy should be performed.

3 Cholangiography, usually performed by a percutaneous transhepatic route, should be performed in

all cases to define the proximal biliary anatomy needed for reconstruction and to allow placement of

biliary catheters to control the ongoing bile leak.

4 Patients with biliary injuries most commonly present in the early postoperative course, usually with

bile leakage. Despite recognition of an ongoing bile leak, urgent return to the operating room should

be avoided.

5 The repair of a bile duct injury recognized in the postoperative period requires a

hepaticojejunostomy in almost all cases and should be performed with transanastomotic biliary

stents.

6 A successful result following repair of a bile duct injury can be expected in 80% to 90% of patients.

Return to a normal quality of life is also expected. In the modern era, death associated with either

bile duct injury or the operative repair is uncommon, occurring in less than 2% of patients.

7 Percutaneous or balloon dilatation of biliary strictures can lead to successful outcomes in selective

patients, although the long-term results generally favor surgical reconstruction.

8 Primary sclerosing cholangitis is an autoimmune disease characterized by intrahepatic and

extrahepatic inflammatory strictures of the bile ducts. Patients are at risk for the development of

cholangiocarcinoma and/or end-stage liver disease. There is no known specific effective medical

therapy for primary sclerosing cholangitis. Primary sclerosing cholangitis has become one of the

most common indications for liver transplantation.

9 Bile duct strictures associated with alcoholic chronic pancreatitis are best managed by biliary bypass.

Biliary injuries and strictures are among the most difficult challenges that a surgeon faces. Although

numerous technologic developments have facilitated diagnosis and management, bile duct injuries and

strictures remain a significant clinical problem. If they go unrecognized or are managed improperly,

life-threatening early complications such as sepsis and multisystem organ failure or late implications of

biliary cirrhosis, portal hypertension, and cholangitis can develop. To avoid these complications,

virtually every patient with a bile duct stricture should undergo evaluation and treatment with the goal

of relieving the obstruction to bile flow and its associated hepatic injury. Finally, the occurrence of a

major bile duct injury during an elective cholecystectomy remains one of the most common indications

for charges of medical practice in the United States.

Benign bile duct strictures can have numerous causes (Table 62-1). Most biliary strictures occur after

primary operations on the gallbladder or biliary tree. With the introduction of laparoscopic

cholecystectomy, bile duct injuries and associated strictures have been seen with increased frequency.

Operative injury to the bile ducts can also occur during nonbiliary operations on the gallbladder or

biliary tree or as a result of external penetrating or blunt abdominal trauma. Inflammatory conditions

and fibrosis caused by chronic pancreatitis, gallstones in the gallbladder or the bile duct, stenosis of the

sphincter of Oddi, or biliary tract infections can also cause benign bile duct strictures. Finally, primary

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