Recurrent Pyogenic Cholangitis Treatment & Management

  • Author: Willis Parsons, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Feb 23, 2010
 

Medical Care

Medical care generally involves parenteral antibiotics, avoidance, and/or prompt recognition and treatment of complications.

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Surgical Care

In some patients, initial medical management may fail and patients may require emergency surgery. These patients often have acute suppurative cholecystitis and require emergent cholecystectomy or percutaneous cholecystotomy (as a temporizing measure). Definitive surgery is directed toward optimizing biliary outflow and is determined by the anatomical extent of involvement. For information on follow-up care, see Further Inpatient Care.

  • Surgery is necessary in patients who have concomitant cholelithiasis or complex hepatolithiasis.[6] The surgical approach is based on the appearance at cholangiography and on axial imaging or MRCP.
    • The usual surgical approach includes the following: (1) cholecystectomy, (2) intraoperative stone clearance by ERCP, (3) percutaneous cholangiography, (4) lithotripsy (ie, mechanical, laser, electrohydraulic), and (5) a definitive biliary drainage procedure.
    • Definitive drainage procedures include operative sphincteroplasty and appropriate biliodigestive bypass.
    • Many surgeons favor performing a Roux-en-Y choledochojejunostomy. Access to the Roux limb for reintervention (if necessary) is achieved percutaneously or endoscopically.

In a retrospective analysis, Lee et al looked at the outcomes of 85 patients who underwent any of the following treatments for recurrent pyogenic cholangitis: hepatectomy (65.9%); hepatectomy combined with drainage (9.4%); drainage alone (14.1%), and percutaneous choledochoscopy (10.6%).[7]

No operative moralities occurred, although 40% of patients suffered complications, half of them involving wound infections. Over a median follow-up period of 45.4 months, patients experienced a residual stone (21.2%), stone recurrence (16.5%), and biliary sepsis recurrence (21.2%), with the greatest incidence of these being in patients who had undergone drainage alone or had been treated with percutaneous choledochoscopy.[7]

In patients who had undergone hepatectomy alone or in combination with drainage, over a median follow-up period fo 42.7 months, the frequency of residual stone was 15.6%, stone recurrence was 7.8%, and biliary sepsis recurrence was 9.4%.[7] Based on the study results, the authors recommended that hepatectomy be considered the treatment of choice for suitable patients with recurrent pyogenic cholangitis.[7]

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Consultations

Optimal management of these cases usually requires many consultants who must work in a synergistic fashion to achieve the desired optimal outcome.

  • Potential consultants include interventional gastroenterologists, interventional radiologists, and hepatobiliary surgeons.
  • Infectious disease experts often help guide the investigation for and the treatment of concurrent helminthic infection.
  • In the minority of patients who present with the complication of cholangiocarcinoma, consultation with an oncology specialist is prudent.
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Diet

Patients who are malnourished require nutritional rehabilitation.

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Contributor Information and Disclosures
Author

Willis Parsons, MD  Medical Director of the GI Center, Northwest Community Hospital

Willis Parsons, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Anil Minocha, MD, FACP, FACG  Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center

Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

James L Achord, MD  Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine

James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

  1. Jeyarajah DR. Recurrent pyogenic cholangitis. Curr Treat Options Gastroenterol. Apr 2004;7(2):91-98. [Medline].

  2. Bass N. Sclerosing Cholangitis and Recurrent Pyogenic Cholangitis. In: Feldman M, Scharschmidt B, Slesinger M, eds. Gastrointestinal and Liver Disease. Vol 1. Philadelphia, Pa: WB Saunders; 1993:1006-25.

  3. Chan FL, Chan JK, Leong LL. Modern imaging in the evaluation of hepatolithiasis. Hepatogastroenterology. Mar-Apr 1997;44(14):358-69. [Medline].

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  6. Al-Sukhni W, Gallinger S, Pratzer A, Wei A, Ho CS, Kortan P, et al. Recurrent pyogenic cholangitis with hepatolithiasis--the role of surgical therapy in North America. J Gastrointest Surg. Mar 2008;12(3):496-503. [Medline].

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