Common emergencies in hepatobiliary surgery: a summary of the article on acute cholangitis

Key points at a glance Acute cholangitis is an infectious disease of the biliary tract caused by secondary infection after partial or complete biliary obstruction.
The common causes of biliary obstruction include intrahepatic and extrahepatic bile duct stones, benign bile duct stricture, iatrogenic stricture, and malignant diseases.
Lead to stenosis of the bile duct.

The typical manifestation of acute cholangitis is the Charcot triad (fever, jaundice, and abdominal pain), which can become a life-threatening disease if it is not recognized early.

Diagnosis requires comprehensive judgment based on clinical manifestations, laboratory examinations and imaging examination results.

The main treatments for acute cholangitis include fluid resuscitation, antibiotic therapy and biliary drainage.

Endoscopic retrograde cholangiopancreatography (ERCP) is still the preferred method of biliary drainage.

Acute cholangitis of common emergencies in hepatobiliary surgery: what is the cause? Acute cholangitis is an infectious disease of the biliary tract caused by secondary infection after partial or complete obstruction of the biliary tract.
It is a common surgical emergency in hepatobiliary surgery.

The most common risk factor for acute cholangitis is choledocholithiasis (approximately half of reported cases), and the second most common cause is malignant obstruction (10%-30% of cases).

Other causes of complete or partial biliary obstruction are shown in Table 1.

Acute cholangitis: how is it diagnosed? The diagnosis of acute cholangitis requires a comprehensive judgment based on clinical manifestations, laboratory examinations and imaging examination results.

Patients with fever, jaundice, and abdominal pain (Charcot triad) should suspect acute cholangitis.

In more severe cases, patients with acute obstructive suppurative cholangitis may experience abdominal pain, chills and fever, jaundice, shock, and psychiatric symptoms (Reynolds' five signs).

Although the Charcot triad has a specificity of greater than 90% in the diagnosis of acute cholangitis, it has a lower sensitivity of 26.
4% and a higher rate of missed diagnosis.The Tokyo Guidelines (revised twice in the 2013 and 2018 editions) are currently the most acceptable diagnostic criteria, based on comprehensive diagnosis based on clinical, laboratory, and imaging results (Table 2).

The diagnosis is clear when there is systemic inflammation (fever and/or laboratory test data), cholestasis and imaging findings (biliary dilatation) or imaging causes.

Note: CRP, C-reactive protein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; ULN, upper limit of normal.

Acute cholangitis: how is it treated? Acute cholangitis must be recognized and treated early, because the mortality rate of the disease increases with the delay of treatment.

The main treatments include active fluid resuscitation, antibiotics, and biliary drainage.

1.
Antibiotic treatment The current guidelines recommend the use of penicillin/β-lactamase inhibitors, third-generation cephalosporins or carbapenem antibiotics for the treatment of ascending cholangitis.

The further selection of antibiotics should consider whether the infection is community-acquired or health care-related, as well as individual risk factors, local resistance patterns, and the risk of adverse outcomes.

The consensus guidelines suggest that the duration of antibacterial treatment ranges from 3 days to 10 days.

The 2018 Tokyo guidelines recommend that the treatment time should last 4-7 days after the cholangitis is controlled.

If there is bacteremia of Gram-positive cocci (such as Enterococcus, Streptococcus), the treatment duration is recommended to be at least 2 weeks, and then the drug withdrawal time is determined according to symptoms, signs, body temperature, white blood cells, and C-reactive protein.

2.
Endoscopic surgery The 2018 Tokyo Guidelines recommend emergency biliary drainage for moderate and severe acute cholangitis.
For patients with mild acute cholangitis, only appropriate antibiotic treatment is required initially, and most patients do not require biliary drainage.

Although the ideal time is not specified, most experts agree that biliary decompression should be performed within 48 hours.

ERCP is still the first choice for biliary drainage.
Treatment of obstruction through biliary sphincterotomy, biliary stent implantation or nasobiliary duct placement can successfully treat more than 90% of cholangitis cases. The only absolute contraindication for ERCP is known or suspected visceral perforation.

Relative contraindications include cardiopulmonary instability, coagulation dysfunction, pregnancy, and severe contrast agent allergy.

If the coagulation disorder cannot be corrected before surgery, it is not recommended that the patient undergo a sphincterotomy.

3.
Percutaneous transhepatic biliary drainage (PTC) percutaneous drainage is generally considered to be the second-line treatment option for patients who have failed ERCP or are not suitable for endoscopic treatment.

Since the procedure does not require intravenous sedation or anesthesia, it may be safer for clinically unstable patients.

Disadvantages of percutaneous drainage include prolonged hospital stay, patient discomfort, increased risk of complications (such as intraperitoneal bleeding, biliary peritonitis, and sepsis), and contraindications include coagulopathy, ascites, and intrahepatic biliary obstruction.

4.
Open surgical drainage When ERCP, PTC and/or endoscopic ultrasound (EUS) treatment is unsuccessful or contraindicated, open surgical drainage is a last resort.

Patients undergoing laparoscopic cholecystectomy combined with transcystic duct/catheter laparoscopic bile duct exploration may consider this method.

The outcome and prognosis of acute cholangitis: early diagnosis and treatment is the key! The severity of acute cholangitis varies greatly.
For mild cholangitis, conservative treatment with antibiotics can achieve satisfactory results.
However, patients with severe cholangitis are often accompanied by septic shock or organ dysfunction.
Treatment with antibiotics alone cannot control the disease.
Urgent biliary decompression and organ support treatment are required, which seriously threatens the life of the patient.

The results of a recent large retrospective multicenter study showed that the in-hospital mortality rate of patients (382 cases) admitted to the intensive care unit (ICU) due to acute cholangitis was as high as 29%.

The severity of organ failure, the cause of obstruction, the local complications of acute cholangitis, and the delay of biliary drainage> 48 hours are risk factors for death.

Therefore, whether patients with acute cholangitis can receive early and effective treatment and prevent the disease from progressing to severe acute cholangitis is particularly important.

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