Ascending cholangitis.pptx

Seminar

1. Case Presentation Presented by: Dr. Collins Saa Bowah (Mmed surgery) Dr. Chiloleti Geofrey (Mmed Urology) Supervised by: Dr. Mwanga June 20 th , 2022

2. Introduction Name: M. K. L Age: 76 years old Marital status: Married Residency: Morogoro rural Informant: Son

3. Known patient who was diagnosed to have obstructive jaundice sec to cholangiocarcinoma 2months ago 2 weeks post PTBD (External biliary drainage)

4. Chief complains i-Fluid leakage per incision site 1/52 ii-Fever 5/7 iii- Abdominal pain 5/7

5. History of presenting illness The patient was apparent well until one week ago when he started observing fluid leakage per incision site. The leakage was yellowish-greenish , which later on was with mixed with puss , the fluid leakage was not associated with foul smelling, it was not itching Has a history of surgical treatment 2 weeks ago due to his illness as part of continue treatment No history of trauma to the surgical site

6. History of presenting illness Abdominal pain, upper part of abdomen, Gradual onset Colicky in nature, progressive Abdominal pain was associated with vomiting for 2 days prior to admission, non projectile, non bilious, mixed with recent food particles Episode of the vomitus was between 2 to 3 per day

7. History of presenting illness Furthermore , he experience low grade fever which started on gradual onset, on and off no specific periodicity More markedly during the night Fever was relieved with taking paracetamol

8. History of presenting illness One month ago Prior to this admission The patient presented with Right upper quadrant pain 6/12 Yellowish discoloration of eye 6/12

9. History of presenting illness Right upper quadrant pain 6/12 -Of gradual onset progressive as time goes dull in nature , Non radiating -Not associated with fever, no vomiting, no nausea -No history of difficulty in swallowing and regurgitation -No history of early satiety and abdominal fullness

10. History of presenting illness -No history of blood in stool , Passing mucoid stool -No history of altered bowel habits -No history of similar condition in the family

11. History of presenting illness Yellowish discoloration of the eye 6/12 -Started on gradual onset, increase in severity -was progressive , not intermittent, not fluctuating -No aggravating no relieving factor

12. History of presenting illness -Associated with passage of deep yellow urine -Associated with generalized body itching, and clay stool colored -No history of bleeding tendency

13. History of presenting illness -No history of deworming habit in his life -There history of living in areas with livestock keeping in his lifetime -There is significant unintentional weight loss -There is history of Alcoholism consumption local beer, for past 40yrs -There is history of cigarrete smoking 10pack-per day

14. History of presenting illness -No history of blood transfusion before the onset to illness, -No history of multiple sexual partners and practicing unprotected sexual intercourse, -No history of tattooing -No history of drug abuse -Has habitual consumer of groundnuts and mushrooms

15. Course of the illness During the course of the illness, the patient visited the MNH on may and an impression of obstructive jaundice secondary to tumor of the head of the pancreas. He took oral herbs in an attempt to remedy the problem prior to visit here at MNH. He was later sent to do a CT Scan outside where he did the scan at Mloganzila hospital.

16. Course of the illness He was managed with a drain into the gall bladder, and discharge home for a revisit after one month. Patient revisited as a known patient with obstructive jaundice two weeks later with pain and discharges from the biliary catheter site . He came with fluid leakage per abdominal wound two weeks with yellowish-green discharge.

17. Course of the illness After several workouts and investigations, the patient was then admitted and reevaluated.

18. ROS Has history of productive cough with whitish sputum for over 10years now. No history of chest pain nor TB No history of Diabetes No history of awareness of heart beat nor difficulty in lying flat. No history of LOC , no history of convulsion.

19. PMH No history of previous hospital admission No history of other chronic illnesses such as CVA, HTN or DM. No history of allergies to food or medications.

20. Family and Social history He is married with seven children Not insure No familial illness he could remember

21. General Examination Elderly man, Alert, and in no apparent respiratory distress but painful distress. severely malnourished, listless and is able to sit up in bed unsupported. No palpable peripheral , supraclavicular, axillary nor inguinal lymph nodes. No oral thrush and neck mass Bilateral grade II pitting edema

22. General Examination Afebrile to touch, non-pallor, No Has a percutaneous drain insitu, no finger clubbing Temp: 38.6 Celsius BP: 82/60 mmHg PR: 80 beats/min SPO2: 98% RR: 18 cycles/min RBG: 15g/dl

23. SHEENT Black and grey hair with normal distribution Skin generally jaundiced Sclera icteric, conjunctiva pale, pupils reflex to light No ear discharge, nor nose discharge

24. Abdominal Examination Scaphoid abdomen, inverted umbilicus and symmetrical Moves with respiration Drain in RUQ insitu Right upper quadrant tenderness, murphy’s sign positive

25. Abdominal Examination Palpable liver and spleen Tympanic percussion note except for anatomic dullness Normoactive bowels sound DRE: Normal anal verge, intact sphincter tone, Prostate grade ii, firm, free rectal mucosa, with palpable semi-solid stool in rectal vault, glove finger stained with fecal material.

26. Respiratory System Examination Normal chest contour, symmetrical and moves with respiration Good air entry bilaterally Normal bilateral tactile vocal fremitus Trachea is centrally located

27. Cardiovascular System Exam Warm extremities, cap refill <2 secs Pulse : See above BP: See above No distended neck veins PMI at 5 th ICS -MCL

28. Neurological Examination GCS: 15/15 Intact cranial nerves Muscle power and Normal muscle tone Intact sensory sensation, normal reflexes

29. Summary M.K.L, a 76years old male patient presented with the chief complaint of Fluid leakage per incision site, fever and Upper abdominal pain Patient previous diagnosed with Obstructive jaundice sec to cholangiocarcinoma +Yellowish discoloration, Body itching, RUQ pain, clay stool + Alcohol consumption + Cigarrete smoking ( 10 pack per day) + Fever P/E +Hypotension + Murmphy sign +Palpable gallbladder +Hypotension

30. Diagnosis Provisional dx: 1 2 Differential dx: 1 2 3

31. Diagnosis Provisional diagnosis: Ascending Cholangitis sec Post PTBD Cholangiocarcinoma Gallbladder tumor Differential Dx: Acute cholecystitis Liver abscess Acute hepatitis

32. Full Blood Picture and Electrolytes Investigation May 25, 2022 June 12, 2022 References WBC 8.66 12.84 4-10 ABS Neutrophils 4.962 11.39 2-6.9 Neutrophils 57.19 88.70 40-80 Lymphocytes(Abs) 2.736 1.212 .6-3.4 Lymphocytes 31.53 9.434 20-40 ABS Monocytes .0336 .1566 0-0.9 Monocytes .3871 Low 1.220 2-10 ABS Eosinophils 0.937 High .0751 0-0.7 Eosinophils 10.80 High .5848 1-6 ABS Basophils .0076 .0078 0-2 Basophils .0880 Low .0605 .02-0.1 RBC 4.277 Low 4.714 4.5-5.5 HBG 11.23 Low 12.44 13-17 HCT 37.91 Low 39.74 40-50

33. Investigation for FULL BLOOD PICTURE and Serum Electrolytes Investigation May 25, 2022 June 12, 2022 References MCV 88.64 84.29 83 - 99 MCH 26.25 Low 26.39 27-32 MCHC 29.62 Low 31.31 31.5 – 34.5 RDW 16.14 Low 15.87 11.6 – 14.8 Platelets 214.7 170.2 150 - 410 potassium 3.7 3.0 3.5 – 5.1 Sodium 135 135 136 - 145 Chloride 103 102 98 - 107

34. Investigation for Renal and Liver Functions Investigation May 25, 2022 June 12, 2022 References Urea Nitrogen 24,1 3.2 – 7.4 Creatinine 150.2 108.2 63.6 –m110.5 ALT(SGPT) 26 26 0 – 55 AST (SGOT) 59 42 5 - 34 C-Reactive Protein 138.1 0 - 5 Direct Bilirubin 165.6 144.7 0 – 8.6 Total Bilirubin 290.3 199.5 3.4 – 20.5

35. Radiology investigation Abdominal ultrasound CT Scan Please see CT Scan on this case.

36. Report for CT Scan Incremental scans were obtained from the diaphragm to the pelvic brim after oral contrast before and after intravenous contrast An enlarged liver about 15.6cm with centrally located necrotic lesion in the right lobe at segment IV measuring 2.8cm X 2.9 cm X 2.1cm. A mass seen at the porta hepatis occupying the common hepatic duct at the confluence of the right and left intrahepatic ducts , measuring 5.5 x 5.6 x 3.4cm. It is associated with markedly dilated intrahepatic ducts. Has mass effect on the adjacent bowel loop and appears to make the gall bladder difficult to be seen.

37. Normal pancreas Enlarged spleen All pelvic organs were normal

38. Final Diagnosis Ascending Cholangitis sec PTBD gall bladder tumor Cholangiocarcinoma Portal hypertension secondary to portal hepatis tumor

39. Management ongoing Metronidazole 500mg T.D.S 5/7 IV ceftriaxone 1g OD 5/7 Inj. Vit. K 10mg O.D Zinc oxide N.G tube feeding TPBD revision` NS, DNS IR review Paracetamol 1g O.D 3/7

40. Current status of the patient (Drain Insitu) Note that the patient’s consent was obtained for this purpose

41. Literature review Cholangitis

42. Introduction Cholangitis is bacterial infection superimposed on biliary obstruction First described by Jean-Martin Charcot in 1850s as a serious and life-threatening illness Causes Choledocholithiasis Obstructive tumors Pancreatic cancer Cholangiocarcinoma Ampullary cancer Porta hepatis Others Strictures/stenosis ERCP Sclerosing cholangitis AIDS Ascaris lumbricoides

43. EPIDEMIOLOGY US: uncommon, and occurs in association with biliary obstruction and causes of bactibilia (s/p ERCP) Internationally: Oriental cholangiohepatitis endemic in SE Asia- recurrent pyogenic cholangitis with intrahepatic/extrahepatic stones in 70-80% Gallstones highest in N European descent, Hispanic populations, Native Americans Intestinal parasites common in Asia Sex Gallstones more common in women M: F ratio equal in cholangitis Age Median age between 50-60 Elderly patients more likely to progress from asymptomatic gallstones to cholangitis without colic

44. Epidemiology In Tanzania, Infectious disease 2014 edition, The case-fatality rate is 7% to 40%, and is highest in patients with hypotension, renal failure, liver abscess, cirrhosis, inflammatory bowel disease, malignant strictures and advanced age, or delays in diagnosis or surgery

45. Pathogenesis Normally, bile is sterile due to constant flush, bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duodenal reflux and ascending infection ERCP or biliary stent insertion can disrupt the Sphincter of Oddi barrier mechanism , causing pathogeneic bacteria to enter the sterile biliary system.

46. Pathogenesis Obstruction from stone or tumor increases intrabiliary pressure High pressure diminishes host antibacterial defense- IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization.

47. Pathogenesis Bacteria gain access to biliary tree by retrograde ascent Biliary obstruction (stone or stricture) causes bactibilia E Coli (25-50%) Klebsiella (15-20%), Enterobacter (5-10%) High pressure pushes infection into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%).

48. Clinical Manifestations RUQ pain (65%) Fever (90%) May be absent in elderly patients Jaundice (60%) Hypotension (30%) Altered mental status (10%) Charcot Triad Found in 50-70% of patients Reynold’ Pentad

49. Additional History Pruritus, acholic stools PMH for gallstones, CBD stones, Recent ERCP, cholangiogram Additional Physical Tachycardia Mild hepatomegaly

50. Diagnosis: Lab values CBC 79% of patients have WBC > 10,000 , with mean of 13,600 Septic patients may be neutropenic Metabolic panel Low calcium if pancreatitis 88-100% have hyperbilirubinemia 78% have increased alkaline phosphatase AST and ALT are mildly elevated Aminotransferase can reach 1000U/L- micro abscess formation in the liver GGT most sensitive marker of choledocholithiasis Amylase/Lipase Involvement of lower CBD may cause 3-4x elevated amylase Blood cultures 20-30% of blood cultures are positive

51. Image: Ultrasonography Advantage: Sensitive for intrahepatic/extrahepatic/CBD dilatation CBD diameter > 6 mm on US associated with high prevalence of choledocholithaisis has a sensitivity of 79-98% Rapid at bedside Can image aorta, pancreas, liver Identify complications: perforation, empyema, abscess

52. Image: Ultrasonography Disadvantage Despite its high sensitivity Not useful for the distal CBD may not always be visible on US due to bowel gas and structures. 10-20% falsely negative normal U/S does not r/o cholangitis acute obstruction when there is no time to dilate Small stones in bile duct in 10-20% of cases

53. Image: CT scan Advantages CT cholangiography enhances CBD stones and increases detection of biliary pathology Sensitivity for CBD stones is 95% Can image other pathologies: ampullary tumors, pericholecystic fluid, liver abscess Can visualize other pathologies- cholangitis: diverticulitis, pyelonephritis, mesenteric ischemia, ruptured appendix Disadvantages Sensitivity to contrast Poor imaging of gallstones

54. Diagnostic: MRCP Magnetic resonance cholangiopancreatography (MRCP) Advantage Detects choledocholithiasis, neoplasms, strictures, biliary dilations Sensitivity of 81-100%, specificity of 92-100% of choledocholithiasis Minimally invasive- avoid invasive procedure in 50% of patients

55. Disadvantage: cannot sample bile, test cytology, remove stone Contraindications: pacemaker, implants, prosthetic valves Indications If cholangitis not severe, and risk of ERCP high, MRCP useful If Charcot’s triad present, therapeutic ERCP with drainage should not be delayed.

56. Diagnostic: ERCP Endoscopic retrograde cholangiopancreatography (ERCP) Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction Advantage Therapeutic option when CBD stone identified Stone retrieval and sphincterotomy Disadvantage Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

57. Tokyo Guideline 2018 Classification of Ascending cholangitis The  Tokyo Guidelines 2018 (TG18)   are a revision of the  2013 guidelines (TG13) , and incorporate new evidence based on validation studies of TG13. Kiriyama et al (2017)   studied 6,063 patients who were clinically diagnosed with acute cholangitis, and found that the TG13 guidelines diagnosed 90% of these patients retrospectively with acute cholangitis. 30-day mortality rates of patients with Grade III, Grade II, and Grade I were 5.1%, 2.6%, and 1.2%, respectively, and increased significantly along with disease severity. Objectively guides diagnosis and management of patients with acute cholangitis in terms of timing and need for biliary drainage and supportive care. Charcot’s triad (fever, right upper quadrant pain, jaundice) has high specificity but low sensitivity for acute cholangitis ( Kiriyama et al 2017 )

58. Patient must have a suspected diagnosis (≥1 item in A + ≥1 item in B or C) or definite diagnosis (≥1 item in A, B, and C) to meet entry criteria for severity grading, see table below: Criteria Part A Systemic inflammation Fever (>38°C/100.4°F) and/or shaking chills Laboratory data: evidence of inflammatory response (WBC <4 or >10 x1,000/ μL and/or CRP ≥1 mg/dL) Part B Cholestasis Jaundice (total bilirubin ≥2 mg/dL) Laboratory data: abnormal liver enzymes (ALP, γ GTP, AST, ALT levels >1.5 x STD) Part C Imaging Biliary dilatation Evidence of the etiology on imaging (stricture, stone, stent, etc.) 

59. Severity grading system Grade III (dysfunction in ≥1 of the following): Cardiovascular dysfunction: hypotension requiring dopamine ≥5 μ g/kg per min or any dose of norepinephrine Neurological dysfunction: disturbance of consciousness Respiratory dysfunction: PaO₂/FiO₂ ratio <300 Renal dysfunction: oliguria or creatinine >2.0 mg/dL Hepatic dysfunction: PT‐INR >1.5 Hematological dysfunction: platelet count <100,000/mm³ Grade II (≥2 of the following conditions): Abnormal WBC count (>12,000/mm³   or <4,000/mm³) High fever (≥39°C/102.2°F) Age ≥75 years Hyperbilirubinemia (total bilirubin ≥5 mg/dL) Hypoalbuminemia (<0.7 x upper limit of normal) Grade I Does not meet the criteria of Grade III or Grade II acute cholangitis at initial diagnosis

60. Grade Acute cholangitis severity Recommendations I Mild Antibiotics and general supportive care; consider biliary drainage if no response to initial treatment II Moderate Antibiotics and general supportive care; early endoscopic or percutaneous transhepatic biliary drainage is indicated III Severe Initial treatment with antibiotics, urgent biliary drainage, appropriate respiratory/circulatory management

61. MANAGEMENT Upon diagnosis of acute cholangitis (regardless of severity) initial treatment generally consists of antibiotics, fluid resuscitation, electrolyte repletion, and appropriate analgesic administration. Grade I (mild): In most cases, initial treatment as above is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment within 24 hrs. Grade II (moderate): Early (within 48 hrs of admission) endoscopic or percutaneous transhepatic biliary drainage is indicated. Grade III (severe): Treat underlying sepsis aggressively with respiratory (tracheal intubation) and circulatory (pressors) support. Emergent (as soon as patient is hemodynamically stable) endoscopic or percutaneous transhepatic biliary drainage is indicated.

62. Medical Treatment Resuscitate, Monitor, Stabilize if patient unstable Consider cholangitis in all patients with sepsis Antibiotics Empiric broad-spectrum Abx after blood cultures drawn Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily) Carbapenems : gram negative, enterococcus, anaerobes Levofloxacin (250-500mgIV qD ) for impaired renal fxn .

63. 80% of patients can be managed conservatively 12-24 hrs Abx - If fail medical therapy, mortality rate 100% without surgical decompression: ERCP or open - Indication: persistent pain, hypotension, fever, mental confusion

64. Surgical treatment Endoscopic biliary drainage Endoscopic sphincterotomy with stone extraction and stent insertion CBD stones removed in 90-95% of cases Therapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression

65. Surgery Emergency surgery replaced by non-operative biliary drainage Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal Elective surgery: low M & M compared with emergency survey If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

66. Referrence 1. Boey JH, Way LW. Acute cholangitis. Ann Surg 1980;191:264-70 2. Csendes A, Diaz JC, Burdiles P, et al. Risk factors and classification of acute suppurative cholangitis. Br J Surg 1992;79:655-8 3. Thompson JE Jr, Tompkins RK, Longmire WP Jr. Factors in management of acute cholangitis. Ann Surg 1982;195:137-45 4. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326:1582-6 5. Wani S, Sultan S, Qumseya B, et al. The ASGE’S vision for developing clinical practice guidelines: the path forward. Gastrointest Endosc 2018;87:932-3 6. Iqbal U, Khara HS, Hu Y, et al. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2020;91:753-60 7. Bramer WM, Giustini D, de Jonge GB, et al. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc 2016;104:240-3 8. Kumar R, Kwek A, Tan M. Outcomes of intensive care unit (ICU) patients with cholangitis requiring percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) [abstract]. Gastrointest Endosc 2016;83:AB247-8 9. Park CS, Jeong HS, Kim KB, et al. Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients. Hepatobil Pancreat Dis Int 2016;15:619-25

67. As for the diagnostic accuracy of diagnostic imaging for malignant tumors, there is a report showing that the sensitivity/specificity/rate of correct diagnosis of US for extrahepatic bile duct cancers are 85.6/76.9/84.4 % for cancers of the hilar bile duct; 59.1/50/57.1 % for cancers of the middle bile duct; and 33.3/42.8/36.8 % for cancers of the lower bile duct, respectively [ 16 ]. There are reports showing that about 100 % of the tumors of the biliary system, except early cancers, are recognized with multi-detector CT and a judgment of the usefulness of resection can be made in 74.5–91.7 % of the cases [ 17 ,  18 ]. A meta-analysis of MRCP has found that its sensitivity and specificity are 97/88 and 98/95 %, respectively, when the detection of obstruction/malignancy has been set as the end point [ 19 ].