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Toronto Notes 2019 Biliary Tract General Surgery and Thoracic Surgery GS49
• requiresprophylacticantibiotics
• contraindications:coagulopathy,ascites,peri/intrahepaticsepsis,anddiseaseofrightlowerlungor
pleura
• complications:bileperitonitis,chylothorax,pneumothorax,biliarysepsis,andhemobilia
Complications
• cholangitis,pancreatitis,biliarystricture,andbiliarycirrhosis
Treatment
• treatwithERCPforCBDstoneextractionpossiblyfollowedbyelectivecholecystectomyin25%of patients
Acute Cholangitis
Pathogenesis
• obstructionofCBDleadingtobiliarystasis,bacterialovergrowth,suppurationandbiliarysepsis–may be life-threatening, especially in elderly
Etiology
• choledocholithiasis(60%),stricture,neoplasm(pancreaticorbiliary),extrinsiccompression(pancreatic pseudocyst or pancreatitis), instrumentation of bile ducts (PTC, ERCP), and biliary stent
• organisms:E.coli,Klebsiella,Pseudomonas,Enterococcus,B.fragilis,andProteus
Clinical Features
• Charcot’striad:fever,RUQpain,andjaundice
• Reynold’spentad:fever,RUQpain,jaundice,shock,andconfusion
• mayhaveN/V,abdominaldistention,ileus,acholicstools,andtea-colouredurine(elevateddirect
bilirubin)
Investigations
• CBC:elevatedWBC+leftshift
• mayhavepositivebloodcultures
• LFTs:obstructivepicture(elevatedALP,GGT,andconjugatedbilirubin,mildincreaseinAST,ALT) • amylase/lipase:ruleoutpancreatitis
• U/S:intra-/extra-hepaticductdilatation
Treatment
• initial:NPO,fluidandelectrolyteresuscitation,±NGT,IVantibiotics(treats80%) • biliarydecompression
■ ERCP + sphincterotomy: diagnostic and therapeutic
■ PTC with catheter drainage: if ERCP not available or unsuccessful
■ laparotomy with CBD exploration and T-tube placement if above fails
• allpatientsshouldalsohaveacholecystectomy,unlesscontraindicated
Prognosis
• suppurativecholangitismortalityrate:50%
Gallstone Ileus
Pathogenesis
• repeatedinflammationcausesacholecystoentericfistula(usuallyduodenal)→largegallstoneentersthe GI track (impactingnear the ileocecal valve) causing a mechanical bowel obstruction (note: ileus is a misnomer in this contex t)
Clinical Features
• crampyabdominalpain,N/V,constipation/obstipation(seeLargeBowelObstruction,GS29)
Investigations
• AXR:dilatedsmallintestine,airfluidlevels,mayrevealradiopaquegallstone,andairinbiliarytree (pneumobilia) (40%)
• CT: biliary tract air, obstruction, and gallstone in intestine
• Rigler’striad:pneumobilia,smallbowelobstruction(partialorcomplete),andgallstone(usuallyinright
iliac fossa)
Treatment
• fluidresuscitation,NGTdecompression
• surgery:enterolithotomyandremovalofstone,inspectsmallandlargebowelforadditionalproximal
stones
• mayclosefistulasurgicallyormanageexpectantly(canresolvespontaneously)
• cholecystectomyisgenerallynotperformed
Charcot’s Triad
Fever, RUQ pain, jaundice
Reynolds’ Pentad
Fever, RUQ pain, jaundice, shock, confusion
Common Bacteria in Biliary Tract
KEEPS
Klebsiella Enterococcus
E. coli, Enterobacter Proteus, Pseudomonas Serratia
Rigler’s Triad of Gallstone Ileus
Pneumobilia
Small bowel obstruction Gallstone
Bouveret’s Syndrome
Gastric outlet/duodenal obstruction caused by a large gallstone passing through a cholecystogastric or cholecystoduodenal fistula