This is one of the most dreaded, non-cancer diagnoses in surgery. Cholangitis means inflammation and infection of the common bile duct. This is the tube-like structure that drains the bile made by the liver into the gallbladder and then, after a person eats, drains the bile into the bowel.
Cholangitis occurs when the outflow into the bowel is blocked by a gallstone or tumor. There is a
buildup of pressure and bile that becomes infected with gram-negative bacteria such as Klebsiella and E. Coli. The signs and symptoms include jaundice (a yellow color to the skin and cornea), fever, and pain in the right upper abdomen or quadrant. This is called Charcot’s triad and occurs in 50% to 70% of cases. If the patient has mental status changes such as confusion or coma and hypotension or a low blood pressure the findings are called Reynold’s pentad.
The best imaging study to diagnose cholangitis is an ultrasound test, which will show a dilated common bile duct (> 0.8-1.0 cm), possible dilated ducts in the liver and sometimes gallstones or a mass.
In cholangitis, emergent treatment is needed as its can rapidly progress to a life-threatening condition. Intravenous antibiotics that will cover the likely bacteria are given such as Unasyn, Zosyn, or a combination of ampicillin, gentamycin, and metronidazole.
In addition, the obstruction must be mechanically relieved. One way is through a procedure callled ERCP (endoscopic retrograde cholangiopancreatography). This is where the patient is placed on their stomach after being sedated and an endoscope is threaded through the mouth and stomach to the area of the common bile duct. Under visualization from a camera on the scope, the gastroenterologist makes a cut in the sphincter that empties the common bile duct and then uses a basket to “fish out the stones”. If no stones are seen, the gastroenterologist sometimes leaves a small hollow tube or stent to keep the duct open.
A second way to relieve the obstruction is through a procedure called PTC or percutaneous transhepatic cholangiography. This is where the interventional radiologist places a needle and catheter through the skin on the right flank, punctures the liver, threads the catheter through the ever-larger bile canals into the common bile duct, and then passes the catheter through the sphincter to prop it open and allow drainage. Sometimes it is possible for the IR doctor to push a stone through the sphincter or to grasp it and pull it back out through the catheter. Almost invariably a catheter is left in place when this procedure is performed.
The third way to relieve the obstruction in the common bile duct is the “old way” – surgery. This procedure is called a common bile duct exploration. It is performed either through the “old incision” made diagonally under the front rib cage or through 4 or 5 smaller incisions if the procedure is done laparoscopically. This is a fairly difficult procedure to do as the tissues around the common bile duct typically are inflammed and the patient can be unstable. Almost all surgeons today would prefer to try either one of the procedures listed above in lieu of operating.
Copyright 2006 Insidesurgery.com