Recurrent Pyogenic Cholangitis Workup

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

Laboratory Studies

  • Complete blood count: A leukocytosis with a left shift is typical in patients with pyogenic cholangitis.
  • Liver function tests: Aminotransferases, serum bilirubin, and alkaline phosphatase typically are elevated in patients with RPC. As with most biliary problems, no predictive or discriminant levels are available to help guide a diagnosis. In other words, any abnormal values in the appropriate clinical setting should prompt a suspicion of RPC, regardless of the degree of liver function test abnormality.
  • Prothrombin time: This may become prolonged if prolonged cholestasis with consequent fat malabsorption and vitamin K deficiency is found. This is important to exclude because hypoprothrombinemia can impact the safety of invasive procedures and is easily correctible with parenteral vitamin K in this setting.
  • Blood cultures: These are mandatory because many patients are bacteremic. The blood culture results often help guide antibiotic choice.
  • Ova and parasites: Clonorchis infection frequently is associated with RPC and should be sought and treated when present.
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Imaging Studies

  • Noninvasive imaging studies: These include transabdominal ultrasound, computed tomography (CT) scans, and magnetic resonance cholangiopancreatography (MRCP).
    • Ultrasound is the preferred initial test during the primary workup. Ultrasound may demonstrate segmental biliary dilatation, hepatolithiasis, and liver abscesses, if present. Ultrasound often determines the choice of supplemental axial imaging techniques.
    • CT scan may demonstrate centrally dilated bile ducts with peripheral tapering. Cholangiohepatitis has a predilection for the left lobe of the liver, and predominantly left-sided findings should prompt consideration of this diagnosis in patients from endemic areas. Other potential findings on CT scan include bile duct stones and pyogenic liver abscesses.
    • The role of MRCP in the investigation of biliary disease continues to evolve in spite of the poor availability of magnetic resonance imaging (MRI) facilities in many regions of the world where RPC is endemic. MRI produces axial images and can be performed to evaluate the portal and hepatic venous system.
      • MR cholangiography may quickly replace endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography as the imaging modality of choice for delineating the biliary tree.
      • In a recent study of 45 patients with RPC who underwent direct cholangiography and MR cholangiography, MR cholangiography demonstrated 100% of all dilated segments, 96% of all strictures, and 98% of all calculi, whereas direct cholangiography demonstrated significantly less, reportedly 44% of all strictures and 45% of all calculi.
      • The role of MRCP is complementary to direct cholangiography, as MRCP, at present, does not offer any therapeutic opportunities.[3, 4, 5]
  • Invasive imaging techniques
    • Cholangiography in the management of RPC is pivotal.
    • The choice of endoscopic (ie, ERCP) versus percutaneous cholangiography hinges on the patient's anatomy and general health status and on the availability of local expertise.
    • Very often, a combination of both techniques is necessary to achieve complete ductal clearance of stones and to ensure that drainage of the biliary tree has been optimized.
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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].

  4. Jain M, Agarwal A. MRCP findings in recurrent pyogenic cholangitis. Eur J Radiol. Apr 2008;66(1):79-83. [Medline].

  5. Heffernan EJ, Geoghegan T, Munk PL, Ho SG, Harris AC. Recurrent pyogenic cholangitis: from imaging to intervention. AJR Am J Roentgenol. Jan 2009;192(1):W28-35. [Medline]. [Full Text].

  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].

  7. Lee KF, Chong CN, Ng D, et al. Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study. HPB (Oxford). 2009;11(1):75-80. [Medline]. [Full Text].

  8. Afagh A, Pancu D. Radiologic findings in recurrent pyogenic cholangitis. J Emerg Med. Apr 2004;26(3):343-6. [Medline].

  9. American College of Surgeons. Surgical education and self-assessment program (SESAP). Recurrent pyogenic cholangitis. Can J Surg. Apr 2004;47(2):121. [Medline].

  10. Carmona RH, Crass RA, Lim RC Jr, Trunkey DD. Oriental cholangitis. Am J Surg. Jul 1984;148(1):117-24. [Medline].

  11. Chen MF, Jan YY, Wang CS, et al. A reappraisal of cholangiocarcinoma in patient with hepatolithiasis. Cancer. Apr 15 1993;71(8):2461-5. [Medline].

  12. Chen PH, Lo HW, Wang CS, et al. Cholangiocarcinoma in hepatolithiasis. J Clin Gastroenterol. Dec 1984;6(6):539-47. [Medline].

  13. Cheng YF, Lee TY, Sheen-Chen SM, Huang TL, Chen TY. Treatment of complicated hepatolithiasis with intrahepatic biliary stricture by ductal dilatation and stenting: long-term results. World J Surg. Jun 2000;24(6):712-6. [Medline].

  14. Chijiiwa K, Yamashita H, Yoshida J, Kuroki S, Tanaka M. Current management and long-term prognosis of hepatolithiasis. Arch Surg. Feb 1995;130(2):194-7. [Medline].

  15. Cosenza CA, Durazo F, Stain SC, Jabbour N, Selby RR. Current management of recurrent pyogenic cholangitis. Am Surg. Oct 1999;65(10):939-43. [Medline].

  16. Digby K. Common duct stones of liver origin. Br J Surg. 1930;17:578.

  17. Koga A, Ichimiya H, Yamaguchi K, Miyazaki K, Nakayama F. Hepatolithiasis associated with cholangiocarcinoma. Possible etiologic significance. Cancer. Jun 15 1985;55(12):2826-9. [Medline].

  18. Lam SK. A study of endoscopic sphincterotomy in recurrent pyogenic cholangitis. Br J Surg. Apr 1984;71(4):262-6. [Medline].

  19. Lee SK, Seo DW, Myung SJ, Park ET, Lim BC, Kim HJ, et al. Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc. Mar 2001;53(3):318-23. [Medline].

  20. Lee Y, Lee BH, Park JH, Suh CH. Balloon dilatation of intrahepatic biliary strictures for percutaneous extraction of residual intrahepatic stones. Cardiovasc Intervent Radiol. Mar-Apr 1991;14(2):102-5. [Medline].

  21. Lim JH. Oriental cholangiohepatitis: pathologic, clinical, and radiologic features. AJR Am J Roentgenol. Jul 1991;157(1):1-8. [Medline].

  22. Min HK. Clonorchis sinensis: pathogenesis and clinical features of infection. Arzneimittelforschung. 1984;34(9B):1151-3. [Medline].

  23. Nakanuma Y, Terada T, Tanaka Y, Ohta G. Are hepatolithiasis and cholangiocarcinoma aetiologically related? A morphological study of 12 cases of hepatolithiasis associated with cholangiocarcinoma. Virchows Arch A Pathol Anat Histopathol. 1985;406(1):45-58. [Medline].

  24. Ng WT. Pathogenesis of acute cholecystitis and recurrent pyogenic cholangitis. Surg Laparosc Endosc Percutan Tech. Aug 2004;14(4):240-1. [Medline].

  25. Saing H, Chan KL, Mya GH, Cheng W, Fan ST, Chan FL. Cutaneous stoma in the roux limb of hepaticojejunostomy (hepaticocutaneous jejunostomy): useful access for intrahepatic stone extraction. J Pediatr Surg. Feb 1996;31(2):247-50. [Medline].

  26. Schulman A. Intrahepatic biliary stones: imaging features and a possible relationship with ascaris lumbricoides. Clin Radiol. May 1993;47(5):325-32. [Medline].

  27. Sheen-Chen S, Chen W, Eng H, Sheen C, Chou F, Cheng Y, et al. Bacteriology and antimicrobial choice in hepatolithiasis. Am J Infect Control. Aug 2000;28(4):298-301. [Medline].

  28. Sperling RM, Koch J, Sandhu JS, Cello JP. Recurrent pyogenic cholangitis in Asian immigrants to the United States: natural history and role of therapeutic ERCP. Dig Dis Sci. Apr 1997;42(4):865-71. [Medline].

  29. Stain SC, Incarbone R, Guthrie CR, Ralls PW, Rivera-Lara S, Parekh D, et al. Surgical treatment of recurrent pyogenic cholangitis. Arch Surg. May 1995;130(5):527-32; discussion 532-3. [Medline].

  30. Tanaka M, Ikeda S, Ogawa Y, et al. Divergent effects of endoscopic sphincterotomy on the long-term outcome of hepatolithiasis. Gastrointest Endosc. Jan 1996;43(1):33-7. [Medline].

  31. Tang CN, Tai CK, Ha JP, Siu WT, Tsui KK, Li MK. Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis. Surg Endosc. Sep 2005;19(9):1232-6. [Medline].

  32. Tang CN, Tai CK, Siu WT, Ha JP, Tsui KK, Li MK. Laparoscopic treatment of recurrent pyogenic cholangitis. J Hepatobiliary Pancreat Surg. 2005;12(3):243-8. [Medline].

  33. Wong WT, Teoh-Chan CH, Huang CT, Cheng FC, Ong GB. The bacteriology of recurrent pyogenic cholangitis and associated diseases. J Hyg (Lond). Dec 1981;87(3):407-12. [Medline].

 
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