Ascending cholangitis: Difference between revisions

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Revision as of 17:31, 15 March 2020

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The definitive treatment for cholangitis is relief of the underlying biliary obstruction.<ref name=Kinney/> This is usually deferred until 24–48&nbsp;hours after admission, when the patient is stable and has shown some improvement with antibiotics, but may need to happen as an emergency in case of ongoing deterioration despite adequate treatment,<ref name=Kinney/> or if antibiotics are not effective in reducing the signs of infection (which happens in 15% of cases).<ref name=schwartz/><ref name=Williams/>

[[Endoscopic retrograde cholangiopancreatography]] (ERCP) is the most common approach in unblocking the bile duct. This involves endoscopy (passing a [[fiberoptic]] tube through the stomach into the duodenum), identification of the ampulla of Vater and insertion of a small tube into the bile duct. A sphincterotomy (making a cut in the sphincter of Oddi) is typically done to ease the flow of bile from the duct and to allow insertion of instruments to extract gallstones that are obstructing the [[common bile duct]]; alternatively or additionally, the common bile duct orifice can be dilated with a balloon.<ref name=Heo>{{cite journal |vauthors=Heo JH, Kang DH, Jung HJ |title=Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones |journal=Gastrointest Endosc |volume=66 |issue=4 |pages=720–6; quiz 768, 771 |date=October 2007 |pmid=17905013 |doi=10.1016/j.gie.2007.02.033|display-authors=etal}}</ref> Stones may be removed either by direct suction or by using various instruments, including balloons and baskets to trawl the bile duct in order to pull stones into the duodenum. Obstructions that are caused by larger stones may require the use of an instrument known as a mechanical [[lithotriptor]] in order to crush the stone prior to removal.<ref name=Caddy>{{cite journal |vauthors=Caddy GR, Tham TC |title=Gallstone disease: Symptoms, diagnosis and endoscopic management of common bile duct stones |journal=Best Pract Res Clin Gastroenterol |volume=20 |issue=6 |pages=1085–101 |year=2006 |pmid=17127190 |doi=10.1016/j.bpg.2006.03.002}}</ref> Obstructing stones that are too large to be removed or broken mechanically by ERCP may be managed by [[extracorporeal shock wave lithotripsy]]. This technique uses acoustic shock waves administered outside the body to break down the stones.<ref name=Hochberger>{{cite journal |vauthors=Hochberger J, Tex S, Maiss J, Hahn EG |title=Management of difficult common bile duct stones |journal=Gastrointest Endosc Clin N Am |volume=13 |issue=4 |pages=623–34 |date=October 2003 |pmid=14986790 |doi= 10.1016/S1052-5157(03)00102-8|url=}}</ref> An alternative technique to remove very large obstructing stones is electrohydraulic lithotripsy, where a small endoscope known as a cholangioscope is inserted by ERCP to directly visualize the stone. A probe uses electricity to generate shock waves that break down the obstructing stone.<ref name=Arya>{{cite journal |vauthors=Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK |title=Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones |journal=Am J Gastroenterol |volume=99 |issue=12 |pages=2330–4 |date=December 2004 |pmid=15571578 |doi=10.1111/j.1572-0241.2004.40251.x|doi-broken-date=2020-03-15 }}</ref> Rarely, surgical exploration of the common bile duct (termed choledochotomy), which can be performed with [[laparoscopy]], is required to remove the stone.<ref name=Karaliotas>{{cite journal |vauthors=Karaliotas C, Sgourakis G, Goumas C, Papaioannou N, Lilis C, Leandros E |title=Laparoscopic common bile duct exploration after failed endoscopic stone extraction |journal=Surg Endosc |volume= 22|issue= 8|pages= 1826–31|date=December 2007 |pmid=18071799 |doi=10.1007/s00464-007-9708-8 |url=}}</ref>

Narrowed areas may be bridged by a [[stent]], a hollow tube that keeps the duct open. Removable plastic stents are used in uncomplicated gallstone disease, while permanent [[Self-expandable metallic stent|self-expanding metal stents]] with a longer lifespan are used if the obstruction is due to pressure from a tumor such as [[pancreatic cancer]]. A nasobiliary drain may be left behind; this is a plastic tube that passes from the bile duct through the stomach and the nose and allows continuous drainage of bile into a receptible. It is similar to a [[nasogastric tube]], but passes into the common bile duct directly, and allows for serial x-ray cholangiograms to be done to identify the improvement of the obstruction. The decision on which of the aforementioned treatments to apply is generally based on the severity of the obstruction, findings on other imaging studies, and whether the patient has improved with antibiotic treatment.<ref name=Kinney/> Certain treatments may be unsafe if [[coagulation|blood clotting]] is impaired, as the risk of bleeding (especially from sphincterotomy) is increased in the use of medication such as [[clopidogrel]] (which inhibits [[platelet]] aggregation) or if the [[prothrombin time]] is significantly prolonged. For a prolonged prothrombin time, [[vitamin K]] or [[fresh frozen plasma]] may be administered to reduce bleeding risk.<ref name=Kinney/>