ACUTE CHOLANGITIS,CARCINOMA OF THE BILE DUCT and Surgical Jaundice

ACUTE CHOLANGITIS Mechanism: obstruction of common bile duct leading to biliary stasis, bacterial overgrowth, suppuratio...

ACUTE CHOLANGITIS

Mechanism:

• obstruction of common bile duct leading to biliary stasis, bacterial overgrowth, suppuration, and biliary sepsis - life threatening

Etiology

1. choledocholithiasis (60%)
2. post-operative stricture
3. pancreatic or biliary neoplasms

Organisms : E. coli, Klebsiella, Pseudomonas, Enterococci, B. fragilis, Proteus

Signs and symptoms :

1. Charcot's triad:
   
   • fever
   • jaundice,
   • RUQ pain
2. Reynold's pentad:
   
   • Charcot's triad +
   • mental confusion,
   • hypotension leading to renal failure

Diagnostic investigations

1. elevated WBC
2. elevated liver function tests and conjugated bilirubin
3. U/S shows gallstones in gallbladder +/- stones seen in bile ducts (approximately 10-15%) +/- dilated extrahepatic or intrahepatic bile ducts

Treatment

1. antibiotics, hydration
2. urgent ERCP - diagnostic and therapeutic with papillotomy to remove stones
3. if ERCP unavailable or unsuccessful, then PTC
4. if ERCP, PTC unavailable, surgery to decompress CBD ----> T-tube
5. if elderly, (usually) don’t have to remove gallbladder if adequate ERCP + papillotomy

CARCINOMA OF THE BILE DUCT 

1. majority adenocarcinoma 
2. 2% of cancer deaths (1/8 as common as pancreatic cancer) 

Associations

1. age 50-70 years
2. age 20-40 if chronic ulcerative colitis, Clonorchis  sinensis (a liver fluke)infestation, sclerosing cholangitis, choledochal cysts
3. female:male = 2:1

Clinical presentation

1. local: RUQ pain, palpable mass (if tumour in CBD)
2. systemic: unremitting jaundice, pruritus, weight loss, anorexia 

Investigations

• Klatskin tumour (at common hepatic duct bifurcation)causes increased ALP, bilirubin, but normal AST

Diagnosis:

• U/S and CT (dilated bile ducts), ERCP and PTC (depict tumour)

Treatment

1. +/- stents for palliation
2. radiation or Whipple's if tumour at low end of CBD

Prognosis

1. spread: growth into portal vein or hepatic artery, liver, hilar nodes
2. 10-15% 5 year survival
3. death results from progressive biliary cirrhosis, persistent intrahepatic infection and abscess formation, or sepsis

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Surgical Jaundice