Professional Documents
Culture Documents
R1
Tokyo guideline
First Guideline for acute cholangitis and
acute cholecystitis
2007, 2013
2013, 11 articles
Cholangitis
Definition
Morbid condition
Acute infection and inflammation in the bile duct
Cholangitis
Pathophysiology
Onset involve 2 factor
Increase bacteria in bile duct
intraductal pressure
Cholangitis
Historical
1887, Charcot use hepatic fever, Charcots triad
1959, Reynold and Dargan use Acute
obstructive cholangitis, Reynolds pentad
Longmires classification (not use)
Acute suppurative cholangitis ~ Charcot triad
Acute obstructive suppurative cholangitis ~ Reynolds
pentrad
Cholecystitis
Definition
Acute inflammation disease of Gall bladder
Cholecystitis
Pathophysiology
Cholecystitis
Pathophysiological classification
Edematous cholecystitis (1st stage, 2-4 day)
GB wall edema, interstitial fluid
Dilate capillaries and lymphatic
Cholecystitis
Pathophysiological classification
Necrotizing cholecystitis (2nd stage, 3-5 days)
Area of hemorrhage and necrosis
Cholecystitis
Pathophysiological
Suppurative cholecystitis (3rd stage, 7-10 dat)
Cholecystitis
Pathophysiological
Chronic cholecystitis
After repeated mild cholecystitis
Chronic irritation of large stone
Mucosal atrophy and fibrosis of GB wall
Cholecystitis
Special form of cholecysitis
Acalculous cholecystitis
Acute cholecystitis without stone
Xanthogranulomatous cholecystitis
Leakage of bile into GB
Rupture of Rokitansky-Anchoff sinus
Bile is ingest by histocytes, forming granuloma => foamy
histocyte
Cholecystitis
Special form of cholecysitis
Emphysematous cholecystitis
Infect by Gas-forming organism (C.perfringen)
Often in DM Pt
Likely progess sepsis and gangrenous GB
Torsion of GB
Inherite (floaing GB)
Aquired (aplanchnoptosis, senild hump back, scoliosis
and weight loss)
Physical factor (sudden change intraperitoneal
Pressure, body position, pendulum-like in antiflexion
position, hyperperistalsis, defecation, blow to the
abdomen
Cholecystitis
Advance form and type of complication
Perforate GB
Biliary peritonitis
Pericholecystic abscess
Biliary fistular
Epidermiology
Incidence in asymptomatic gall stone
Epidermiology
Incidence in asymptomatic gall stone
Epidermiology
Incidence of severe case of cholangitis
Shock 7-25%
Conscious disturbance 7-22%
Reynolds pentad 3.5-7.7%
Epidermiology
Incidence of severe case of cholecystitis
Epidermiology
After ERCP
Etiology
Acute cholangitis
Bileduct obstruction => cholestasis
Bacterial growth
Etiology
Acute cholangitis
Etiology
Acute cholangitis
Etiology
Acute cholecystitis
Etiology
Risk factor
Etiology
Drug
Etiology
Other etiology of acute cholangitis
Mirizzi syndrome
Type I: compress from stone in GB neck and cysti duct
Type II: bililobiliary fistular
Lemmel syndrome
Duodenal parapapillary diverticulum
Compress bile duct
Prognosis
Mortality
Acute cholangitis
50% in 1980, 10-30% in 1981-1990, 2.7-10%
after 2000
Recurrence
After conservative treatment
Recurrence
After EST or EPBD
TG07
Sensitivity 84.9%
Specificity 50%
TG13
Sensitivity 92.1%
Specificity 93.3%
Pericholecystic fluid
Sonographic Murphys sign (sen 63%
,spec93%)
Doppler sre useful (Lv C recommendation)
MANAGEMENT
Management
Cholangitis
Management
Cholecystitis
Manage bundle
Management bundle
ANTIMICROBIAL AGENT
Antimicrobial agent
Antimicrobial agent
Less invasive
Technique
U/S guide transhepatic puncture by 18-22G needle
Confirm backflow, guide wire
7-10 Fr catheter is place under fluoroscope
Technique
Standard canulate or wire guide canulate, no
staistical significant difference
ENBD or EBS, no statistical significant difference,
ENBD is not suggest in poor compliance Pt
Technique
After cannulation
Small balloon up to 8-mm insert into the bile duct
Dilate sphincter of Oddi
Clearance of stone by basket or balloon catheter
SURGICAL MANAGEMENT OF
ACUTE CHOECYSTITIS