Bile ducts, gallbladder, gallstones.pdf

Management of patients with obstructive jaundice, surgical biliary disease and gallbladder conditions. MANAGEMENT OF OBSTRUCTIVE JAUNDICE Patients with obstructive jaundice should be discussed for admission and work-up in hospital upon suspicion of the diagnosis and can present to hospital extreme...

Management of patients with obstructive jaundice, surgical biliary disease and gallbladder conditions. MANAGEMENT OF OBSTRUCTIVE JAUNDICE Patients with obstructive jaundice should be discussed for admission and work-up in hospital upon suspicion of the diagnosis and can present to hospital extremely ill. Resuscitation as needed takes precedence and can include IV uids, antibiotics and analgesia. Any patient with obstructive jaundice and fever/rigors or raised white cell count is considered to have cholangitis. The treatment and diagnositic pathway often run alogside each other with urgency. Special points to consider are: Infection – Patients with evidence of Cholangitis receive broad spectrum IV antibiotic(s) to bring the infection under control. Augmentin is a good choice, while Cipro axacin and Metronidazole are a good alternative for those with Penicillin Allergy. Coagulation – Patients receive Vitamin K 5-10mg IV if their INR is increased or if their jaundice will not be relieved soon. INR is tested routinely in these patients, especially if they are to undergo invasive procedures. Renal Function – Patients with obstructive jaundice are at particular risk of acute kidney injury and must not be allowed to become dehydrated. Intravenous uids are liberally used, especially in the presence of cholangitis or when patients are being fasted prior to a procedure, but care is always taken not ot overload patients, esp. those with cardiac conditions. Most patients require some form of intervention or surgery to relieve the obstruction and to deal with the obstructing lesion, as this may require removal in its own right (i.e. a tumour). Detail of various procedures is not expected from the undergraduate student. Principles are as follows: Remove intraluminal cause of obstruction (e.g. Gallstone – see later). Resection of malignant lesion: if the tumour is resectable operations such as a pancreatico-duodenectomy are performed with the aim of cure, with biliary reconstruction (anastomosis between the transected Bile Duct(s) above the lesion and Small Bowel). Thus the underlying pathology is addressed and the Jaundice relieved at the same time. In some cases a stent is placed by ERCP before major resections if surgery will be delayed, to administer neo-adjuvant chemotherapy or to improve patient tness Stents are placed to relieve obstructed biliary systems by ERCP or PTC for patients with unresectable tumours or with metastatic disease. Stents are also placed for some patients to treat strictures of the distal bile duct, e.g. chronic pancreatitis with biliary compression. On occasion some obstructions will be bypassed surgically, by constructing an anastomosis between the bile duct and the small bowel (- Roux-en-Y Hepatico-jejunostomy) fi fl fl fl Other – Addressing a lesion outside of the Biliary Tract & causing extrinsic obstruction (may require treatment in its own right anyway) e.g. Drainage of Pancreatic Pseudocyst. GALLBLADDER Symptomatic Gallstones Patients usually develop symptoms due to gallstones before presenting with a gallstone-related complication such as acute cholecystitis, common bile duct stones or biliary pancreatitis. Once symptoms have been attributed to gallstones (gallstone dyspepsia, biliary colic), an indication for cholecystectomy exists. This is a good time to o er surgery, which avoids the risks of future complications and eliminates symtoms. Laparoscopic cholecystectomy is the operation of choice. Contra-indications to cholecystectomy in symptomatic patients are poor performance status(un t for general anaesthesia) and patient refusal after adequate counselling. Cholecystectomy can be complicated by post-operative bleeding from the surgical eld, bile leaks, bile duct injury and port-site hernias. Management of Acute Cholecysitis - The diagnosis and severity of acute cholecystitis is de ned by the Tokyo Guidelines. In general most patients require: - Admission to Hospital, IV uid resuscitation, Nil per mouth, analgesia, broad spectrum IV antibiotics. - Analgesia – opioids usually required - Antibiotics – Organisms, if present, are mainly Gram –ve. E.coli most common, followed by Klebsiella, Enterococcus faecalis, Proteus and Enterobacter. Augmentin or a second generation cephalosporin and metronidazole are good choices. A combination of Cipro oxacin and metronidazole is used for penicillin allergy. - - At TBH & most other places, the policy is then to schedule surgery (Cholecystectomy) for the rst available operating list (preferably within 3 or 4 days). - Alternative policy (used in previous years) was to treat Acute Cholecystitis medically and to operate electively 6 weeks later. - Indications for urgent surgery for Acute Cholecystitis, i.e. not waiting until the next available elective theatre list:- Patient remaining toxically ill despite medical therapy. Perforation - Diffuse peritonitis (free perforation) - Tender gallbladder mass/swinging temperature (peri- cholecystic abscess) Increased risk of Perforation. fi fl fl ff fi fi fi  - Critically ill patients that are not t for cholecystectomy can be treated with percutaneus drain placement in the obstructed gallbladder lumen (percutaneous cholecystostomy), followed by cholectstectomy at a later stage. Cholecystostomy can also be used in patients with contained gallbladder perforations as a temporising measure. Carcinoma of the Gallbladder * A condition with a very poor prognosis if it has already spread beyond the wall of the Gallbladder. * Prognosis best if incidentally discovered on histology following elective cholecystectomy. * Advanced disease presents with jaundice (in ltration of the bile duct) or with metastatic disease and in these situations there is very little that can be done in terms of meaningful therapy BILE DUCTS Obstruction of the bile duct results in obstructive jaundice (discussed above). If signs of sepsis are present or suspected, patients are managed as cholangitis patients. Antibiotic administration and avoidance of dehydration are paramount in such patients, as they are at high risk of severe sepsis and organ failure at an earlier stage than other forms of sepsis. Always consider cholangitis in patients with unexplained sepsis and jaundiced patients. Patients may not be clinically jaundiced and just have fever and deranged LFT with a slight biochemical rise in bilirubin levels. Common bile duct stones Patients present with obstructive jaundice and the diagnosis is supported by ultrasound ndings. Ultrasound has around 40% sensitivity for common bile duct(CBD) stones, but in a patient with painful obstructive jaundice and an ultrasound which at least shows stones in the gallbladder and dilation of the CBD >7mm, the diagnosis of a stone in the bile duct is supported even if it is not directly visualised. Patients with suspected CBD stones are treated with IV uids, antibiotics and analgesia. This supportive management can be continued for 2 to 3 days with monitoring of symptoms and a daily total bilirubin test. (Do not repat full FLT daily - it is expensive and unnecessary). This conservative approach recognises the possibility that the stone in the duct may pass spontaneously through the Ampulla of Vater. If this has happened the patients will report relief of their colic and the bilirubin will normalise. A same-admission laparoscopic cholecystectomy is then scheduled before they are discharged. An intra-operative cholangiogram is performed during the cholecystectomy to con rm that the CBD stone has actually passed. In patients where pain persists or bilirubin levels increase, an ERCP procedure is scheduled to remove the CBD stone. Once the stone has been successfully removed, a same-admission cholecystectomy is performed. Patients that develop sepsis are managed as fot cholangitis below. Cholangitis Cholangitis is a potentially life-threatening condition. The severity of cholangitis does not always directly correlate with the depth of jaundice and patients can present with organ failure (shock, renal failure) early on in their course and with low raised bilirubin levels. Reynold’s pentad (added confusion or hypotension to Charcot’s triad) raises suspicion of severe cholangitis. fi fi fi fl fi  The Tokyo guidelines de ne the severitu of chaolangitis if you are interested in further reading. In practice patients will either have mild cholangitis or more severe cholangitis. The mild cholangitis is for example a patient with signs of sepsis but who does well with antibiotics and IV uid administration. They are then montired with daily bilirubins to assess if the stone has passed, after which a cholecystectomy and IOC is done. Patients that do not respond to resuscitation, have signi cant co-morbid diseases, are elderly or who have organ failure are managed as severe cholangitis. Preferably in a high-care setting with close monitoring. In addition to uids, antibiotics and organ support, biliary drainage is prioritised in these patients to drain the source of sepsis. Biliary drainage can be achieved by ERCP or PTC. In some cases a cholecystostomy is the only option. After recovery a cholecystectomy is performed. Cholangiocarcinoma Adenocarcinoma of the bile duct can occur in the liver (intrahepatic bile ducts) or in the extrahepatic bile ducts. Intrahepatic cholangiocarcinoma presents as a liver mass with wieght loss and right upper quadrant abdominal pain. Jaundice is not a typical feature of intrahepatic cholangiocarcinoma. In the extrahepatic bile duct the common sites for cholangiocarcinoma are at the biliary con uence in the hepatic hilum = perihilar cholangiocarcinoma (also known as Klatskin tumours), or in the distal common bile duct = distal cholangiocarcinoma. Patients with extrahepatic cholangiocarcinoma present with painless obstructive jaundice and loss of weight. After diagnosis they are staged and treatment assigned accoring to resectability, metastases and tness. fl fl fi fl fi fi