Transcript biliary er

Biliary Emergencies
Murad Aljiffry
MD FRCSC
Case 1
61 year old male
 Abdominal pain for 5 days
 Associated with:
 Fever, malaise, chest pain with
shortness of breath and anorexia
 Past Hx.: diverticulitis treated
 Physical examination
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HR 120, B/P 100/60
 Localized RUQ peritoneal findings
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Case 1
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Lab:
WBC: 18, Hb: 10,
 Creat 130, T.bili 60, ALP 350, Alb 25
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US:
Hypoechoic liver lesion with thickened
irregular wall
 Gall stones
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What next?
Case 1
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Abdominal CT (contrast-enhanced)
Hypodense lesion of left lobe(5.5cm)
occupies segment II and III
 well demarcated, round
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Liver Abscess
Pyogenic(80%): E. coli, K.P
 Paracytic(10%): Entamaeba
histolytica
 Others(10%): candida
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Epidemiology
Incidence in the US is 8-15 per
100,000
 Male to female ratio is 2:1 in recent
studies
 5th-7th decades of life
 Risk factors : DM, underlying
hepatobiliary or pancreatic
malignancy, and liver transplant
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Etiology
Biliary disease accounts for 20-40%
 Extrahepatic obstruction leading to
ascending cholangitis and abscess

CBD stones
 Benign and malignant tumors
 Biliary enteric anastamoses or
manipulation
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Etiology
Infection via portal system
 Infectious process originates in
abdomen, reaches liver by
embolization through portal system
 Appendicitis, diverticulitis, IBD,
proctitis
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Etiology
Hematogenous via hepatic artery
 From systemic septicemia such as
endocarditis and pyelonephritis
 Direct extension or trauma
 No cause (cryptogenic) in 20-40% of
cases
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Etiology
Underlying etiology of 1086 cases of liver abscess compiled
from the literature
Microbiology
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Most contain more than one organism
Blood cultures positive in 33-65%
E.Coli
Klebsiella (is an important emerging
infection associated with endophthalmitis )
Bacteroides
Streptococcal (including S. aureus and S.
pyogenes)
Candida species : usually occurs in
immunosuppressed patients
Microbiology
Microbiologic results from 312 cases of liver abscess compiled
from the literature
Clinical
Fever (85-100%), abdominal pain
(50-75%)
 About one-half of patients with liver
abscess have hepatomegaly, RUQ
tenderness, or jaundice
 Right shoulder pain, pleuritic chest
pain
 Anorexia, weight loss, mental
confusion
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Diagnosis-Lab
CBC: anemia in 50-80%, leukocytosis
in 75-96%
 LFTs: elevated alkaline phosphatase
95-100%, elevated AST, ALT 40-60%
 Elevated bilirubin in 20-50%
 Decreased albumin in 71-87%
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Diagnosis-Imaging
CT and ultrasound are the modalities
of choice (80-100% sensitive)
 An abscess appears radiologically as a
fluid collection with surrounding
edema and inflammation (rim
enhancement) that may contain
loculated subcollections and gas
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Treatment
Initiation of antibiotic therapy
 Diagnostic aspiration and drainage of
abscess
 Surgical drainage in selected patients
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Antibiotic Therapy
Empiric broad-spectrum antibiotics
(draw blood culture before)
 A third generation cephalosporin such
as ceftriaxone + metronidazole
 Fluoroquinolone (eg, ciprofloxacin) +
metronidazole
 Monotherapy with a carbapenem or
an extended spectrum penicillin
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Antibiotic Therapy
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Immunocompromised patients with
multiple abscesses are best treated
with high dose antibiotics rather than
open or percutaneous drainage
Drainage
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For single abscesses with diameter ≤5 cm :
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For single abscesses with diameter >5 cm :
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percutaneous catheter drainage or needle
aspiration is acceptable (usually multiple)
Percutaneous management (catheter drainage
no needle aspiration)
Some favor surgical intervention over
percutaneous drainage, treatment failure lower
with surgical drainage
Success 70-90%
Complications of
Percutaneous Drainage
Perforation of a viscous
 Pneumothorax
 Bleeding
 Leakage of pus into the abdomen
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Surgical Therapy
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Indications of surgical drainage:
Co-existing intra-abdominal disease that
requires operative management
 Failure of percutaneous drainage
 Multiple abscesses
 Loculated abscesses
 Abscesses with viscous contents
obstructing the drainage catheter
 Ascites or coagulopathy
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Surgical Therapy
Transthoracic, extraperitoneal,
transperitoneal
 Transperitoneal is preferred as intraabdominal pathology can be dealt
with
 Laparoscopic or open
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Duration of therapy
Follow imaging, WBC count and
serum CRP
 Drainage catheters should remain in
place until drainage is minimal
 Patients should be treated for 2-4
weeks
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Complications
Result from rupture of abscess into
adjacent organs or cavities
 Pleuropulmonary include effusions,
empyema, bronch-hepatic fistula
 Intraabdominal include subphrenic
abscess, rupture into peritoneal
cavity, or any intraabdominal organ
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Prognosis
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Mortality rate : 10- 20%
If untreated fatal (100% mortality rate)
Mortality appears to be related to
underlying comorbidities rather than to the
abscess itself
Poor prognosis: age >70, multiple
abscesses, polymicrobial infection,
immunosupression, malignancy, and delay
diagnosis
Questions?
Case 2
40 y.o. female presents to ER with 12
hr history of upper abdominal pain
and fever
 Associated nausea and vomiting
 Lab: wbc 12, AST100, ALT220,
GGT1400, ALP 1340, Tbili 75
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Case 2
Amylase and Lipase slight elevation
 U/S – multiple small stones in
gallbladder, CBD9mm, no intrahepatic
dilatation
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What next?
Case 2
H/O gastric bypass
 2:00 am
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Acute Cholangitis
Pus under pressure
 May be difficult to distinguish from
acute cholecystitis
 Managed medically with support,
antibiotics
 Drainage is key
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Etiology
Stone disease
 Anomalous PBJ
 Malignant biliary obstruction
 Primary sclerosing cholangitis
 Post instrumentation
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Cholangiography
 Surgery
 Sphincterotomy
 Stents
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Microbiology
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80% patients +ve biliary cultures
(multiple organisms frequent )
E.Coli (commonest)
 Enterococci
 Klebsiella sp
 Proteus sp
 Pseudomonas sp
 Bacteroides sp
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Clinical Presentation
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Charcot’s triad
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Pyrexia, Pain, Jaundice
Elevated liver enzymes
 Leukocystosis
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Diagnosis
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Clinical
Ultrasound
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CT
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Duct dilation
Presence of gallbladder or CBD stones
Duct dilation
R/O other causes
MRCP (especially for hilar obstruction, if
stable pt.)
ERCP (generally for therapy)
Management
Fluid resuscitation
 Triage (floor or ICU)
 Correction of coagulopathy and
electrolytes
 Blood cultures
 Antibiotics (broad spectrum)
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Management
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Most pt will respond and will require
urgent biliary decompression
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10-15% of patients fail to respond or
deteriorate within 12-24 hours, thus
require emergent biliary
decompression
Biliary Drainage
Endoscopic
 Surgical
 Percutaneous
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Endoscopic Biliary Drainage
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Can be done at bedside in ICU with
portable flouroscopy
Superior to surgical drainage
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Mortality of endoscopic vs surgical drainage
10% vs 32% RCT (Lai NEJM 1992)
Preferable to percutaneous drainage
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Morbidity less (Sugiyama Arch Surg 1997,
AmJGastro 1998)
Especially in presence of ascites, coagulopathy
Endoscopic Biliary Drainage
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Sphincterotomy
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Caution due to bleeding risk
Stone removal
 Stent
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Percutaneous Biliary drain
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When endoscopic drainage fails
Inaccessible papilla
 Roux-en-Y
 Hepatolithiasis
 Segmental cholangitis (complex hilar
tumor)
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Surgical Biliary drain
Last resort
 Decompression of biliary tree and
placement of T tube
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Questions?