Recurrent Pyogenic Cholangitis Treatment & Management
- Author: Praveen K Roy, MD, AGAF; Chief Editor: Julian Katz, MD more...
Patients must be treated with a multidisciplinary approach by multiple subspecialists; therefore, referral to a tertiary center is prudent. Preferably, care should be rendered by individuals who are regional experts in interventional endoscopy, radiology, and hepatobiliary surgery.
Medical care generally involves parenteral antibiotics, avoidance, and/or prompt recognition and treatment of complications. Patients who are malnourished require nutritional rehabilitation.
A biliary drainage procedure is necessary to achieve resolution of the initial infection and to pursue the ultimate goal of preventing further attacks of recurrent cholangitis. The choice of biliary drainage procedure should hinge on patient presentation, comorbidities, cholangiographic findings, and local expertise. To prevent further attacks of cholangitis, these patients are best treated using a multidisciplinary approach of interventional gastroenterology, interventional radiology, and gastrointestinal surgery. Referral to an institution with considerable experience in the management of complex biliary disease is prudent.
Initial biliary decompression is achieved at ERCP, which also allows for the delineation of the biliary tree, an essential step in the planning of the definitive decompressive procedure. Sphincterotomy, stricture dilatation, and placement of a biliary endoprosthesis (stent) often are necessary to achieve biliary decompression and, when appropriate, to alleviate stasis or luminal compromise in the biliary tree, thus preventing further episodes of pyogenic cholangitis. The results of endotherapy appear to be durable in well-selected patients.
Following hospital discharge, careful follow-up with meticulous imaging studies and serial liver function tests is prudent. These studies often provide the first clue that full clearance of the bile ducts has not been achieved or that stone formation has recurred.
Little or no data are available on prevention; however, an overall improvement in living standards appears to parallel a decline in incidence of this disease.
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.[8, 9] The surgical approach is based on the appearance at cholangiography and on axial imaging or MRCP. Note the following:
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%).
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.
In patients who had undergone hepatectomy alone or in combination with drainage, over a median follow-up period of 42.7 months, the frequency of residual stone was 15.6%, stone recurrence was 7.8%, and biliary sepsis recurrence was 9.4%. Based on the study results, the authors recommended that hepatectomy should be considered the treatment of choice for suitable patients with recurrent pyogenic cholangitis.
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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