STRATEGY OF paraclinical exploration of cholangitis
What exploration strategy?
The exploration of the biliary tract imaging is essential in case of suspicion of cholangitis. Ultrasound is a simple and easily accessible. It must be done systematically and the first for all patients with suspected cholangitis, even if only to affirm or deny the existence of a dilatation of the bile ducts.
The sensitivity of ultrasound is not sufficient to remove a gallstone in the bile duct in cases of negative ultrasound. However, the specificity is excellent and if ultrasound finds a calculation of the common bile duct, it is not necessary then to make additional imaging examination.
CT has better sensitivity than ultrasound and will be particularly useful in those who have echogenic or when the common bile duct and the lower common bile duct are completely inaccessible to ultrasound. As with ultrasound, specificity, subject to few to recognize the pitfalls that can generate false positives, is excellent, allowing to postpone any further exploration when a calculation is detected by computed tomography. Its sensitivity is not sufficient to exclude a calculation when the CT is negative.
MRI cholangiography and endoscopic ultrasonography are the most effective techniques for the diagnosis of calculation of the common bile duct. MRI cholangiography offers many benefits, it is totally non invasive, it provides a precise mapping of the entire biliary tree, very similar to that obtained by direct cholangiography.
Provided to add to cholangiographic sequences T1-weighted sequences with gadolinium injection and T2 sequences morphological type fast, it provides a comprehensive exploration of the liver, biliary tree and pancreas to detect other pathology sphere liver, biliary or pancreatic.
However, MR cholangiography is less effective than endoscopic ultrasonography for the detection of micro-calculations (less than 3 mm) and research computing locked at the ampulla of Vater.
The endoscopic ultrasonography is the most sensitive technique for the detection of calculation, the sensitivity does not depend on the size of the calculations in contrast to other imaging techniques. Instead, it explores the less intrahepatic bile ducts and the hepatic hilum. Of course, this review is much more invasive as it requires general anesthesia.
In cases of suspected cholangitis, three clinical situations must be distinguished: 1) patient without previous surgery with gallbladder in place, 2) patient with a history ofcholecystectomy surgery but no common bile duct, 3) patient with a history of biliary surgery and in particular biliary-digestive anastomosis.
Gallbladder in place
When migration is suspected more or less complicated gallstone cholangitis in a patient with no history of biliary surgery or gallbladder, the role of the radiologist is to consolidate the ultrasound clinical and laboratory data suggestive of gallstone migration.
One of the first things to check is the presence of calculus in the gallbladder. This research must be careful so no calculation is immediately visible. We help each probe at high frequency and positional maneuver.
Indeed, in the absence of gallstones, gallstone migration is possible (migration of a single vesicle calculation) but the probability is low. The lack of calculation in the gallbladder will cause to search for anotherobstruction and bile stasis and in particular a tumor of the ampullary region or a non-biliary disease.
When gallstones are found on ultrasound, the radiologist will work to find a dilated intrahepatic bile ducts and extrahepatic, as far as the common hepatic duct at the junction of the hepatic artery should be performed accurately.
Then there is an expansion or not, the ultrasound will seek insistently a calculation of the lower bile duct. For this it is essential to help positional maneuvering to use the patient's inspiratory variations to identify the portion retro-pancreatic and peri-ampullary lower bile duct. The poor sensitivity of ultrasound does not eliminate the diagnosis of calculation of the common bile duct when it is negative.
Evidence from ultrasound (presence of gallstones, any signs of cholecystitis, dilation of the bile duct) will assist the clinician in conjunction with clinical and laboratory data to determine whether the acute, painful, the patient is related to a problem or not gallstone migration.
Many scores can be calculated from the ultrasound data, biological and clinical. These scores generally reflect the age, the presence of gallstones less than 10 mm, a bile duct over 10 mm, a cholecystitis, to determine the likelihood of calculation of the common bile duct in preoperatively. Other scores combine ultrasound data to disturbances of liver function tests.
Quality standards, established by the learned societies of surgery in France, are expected to require the production of direct cholangiography (or intraoperative ultrasound) during cholecystectomy. If intraoperative cholangiography isactually carried out a systematic, research preoperative calculation of the common bile duct is not required.
This prevents the proliferation of pre-operative examinations when clinical, laboratory, and ultrasonographic characteristics are consistent and cholangitis in gallstone migration. Ultrasound is the imaging technique when necessary and sufficient for the exploration of patients with suspected cholangitis.
But when clinical and laboratory data are not typical, that patients are not echogenic, or intraoperative cholangiography is not perfectly controlled and / or systematically destroyed by the surgical team, a precise morphological exploration of the way preoperative biliary required. Cholangiography by MRI at this stage considering the most effective non-invasive.
In severe forms immediately, the realization of a scanner with an emergency acquisition without and after injection of iodine in the absence of renal failure is entirely lawful.
CT easily detect complications (pylephlebitis, abscess, pancreatitis) or catch an incorrect clinical diagnosis by demonstrating an alternative diagnosis.
History of cholecystectomy
In patients with a history of cholecystectomy, the problem is very different, since the pre-treatment examinations should determine whether the patient should be given whether or not a retrograde cholangiopancreatography with sphincterotomy.
The significant risk of such treatment (pancreatitis, infectious complications, hemorrhagic complications of sphincterotomy) justifies the existence of one or more calculations the common bile duct are formally individualized to indicate that gesture.
If the ultrasound does not reveal a stone in the common bile duct, other imaging investigations are needed. In subjects not echogenic, and when we could not adequately explore the common bile duct and common bile duct, the realization of a CT scan is a simple and rapid method which allows in some cases to confirm the existence of a calculation. However, examination of reference in this circumstance are MR cholangiography and endoscopic ultrasonography.
The endoscopic ultrasonography offers the advantage of being performed immediately before ERCP possible which will be indicated if endoscopic ultrasonography found a calculation. This is the strategy to be adopted for calculating the suspicion is strong.
On the contrary, the suspicion of calculation is lower, it is preferable to perform MRI cholangiography much less invasive, although its sensitivity is slightly worse than the echo-endoscopy eliminates a great value negative predictive diagnosis for calculating the bile duct.
History of surgery for bile duct
The latter circumstance for patients with a history of surgery of the bile duct and in particular of biliary-digestive anastomosis.
In these patients, cholangitis occur in an atypical way and are not necessarily linked to the presence of gallstones, but most often due to stenosis of the biliary-digestive anastomosis. Calculations, when present, follow the bile stasis and chronic infection that favor the formation of intraductal material.
If cholangitis, patients have a table overlooking infectious, often severe, with septicemia associated with cytolysis and anicteric cholestasis or not. The pain is often rough at times kind of heaviness in the right hypochondrium.
Ultrasound, which must be performed as first-line, not always found in bile duct dilatation, strictures, or because sometimes incomplete. Cholangiography by MRI has become the gold standard for exploring this type of patient.
It allows precise mapping of the bile ducts above the anastomosis and anastomotic. It is essential for any therapeutic decision, whether further surgery or percutaneous biliary drainage.
The exploration of the biliary tract imaging is essential in case of suspicion of cholangitis. Ultrasound is a simple and easily accessible. It must be done systematically and the first for all patients with suspected cholangitis, even if only to affirm or deny the existence of a dilatation of the bile ducts.
The sensitivity of ultrasound is not sufficient to remove a gallstone in the bile duct in cases of negative ultrasound. However, the specificity is excellent and if ultrasound finds a calculation of the common bile duct, it is not necessary then to make additional imaging examination.
CT has better sensitivity than ultrasound and will be particularly useful in those who have echogenic or when the common bile duct and the lower common bile duct are completely inaccessible to ultrasound. As with ultrasound, specificity, subject to few to recognize the pitfalls that can generate false positives, is excellent, allowing to postpone any further exploration when a calculation is detected by computed tomography. Its sensitivity is not sufficient to exclude a calculation when the CT is negative.
MRI cholangiography and endoscopic ultrasonography are the most effective techniques for the diagnosis of calculation of the common bile duct. MRI cholangiography offers many benefits, it is totally non invasive, it provides a precise mapping of the entire biliary tree, very similar to that obtained by direct cholangiography.
Provided to add to cholangiographic sequences T1-weighted sequences with gadolinium injection and T2 sequences morphological type fast, it provides a comprehensive exploration of the liver, biliary tree and pancreas to detect other pathology sphere liver, biliary or pancreatic.
However, MR cholangiography is less effective than endoscopic ultrasonography for the detection of micro-calculations (less than 3 mm) and research computing locked at the ampulla of Vater.
The endoscopic ultrasonography is the most sensitive technique for the detection of calculation, the sensitivity does not depend on the size of the calculations in contrast to other imaging techniques. Instead, it explores the less intrahepatic bile ducts and the hepatic hilum. Of course, this review is much more invasive as it requires general anesthesia.
In cases of suspected cholangitis, three clinical situations must be distinguished: 1) patient without previous surgery with gallbladder in place, 2) patient with a history ofcholecystectomy surgery but no common bile duct, 3) patient with a history of biliary surgery and in particular biliary-digestive anastomosis.
Gallbladder in place
When migration is suspected more or less complicated gallstone cholangitis in a patient with no history of biliary surgery or gallbladder, the role of the radiologist is to consolidate the ultrasound clinical and laboratory data suggestive of gallstone migration.
One of the first things to check is the presence of calculus in the gallbladder. This research must be careful so no calculation is immediately visible. We help each probe at high frequency and positional maneuver.
Indeed, in the absence of gallstones, gallstone migration is possible (migration of a single vesicle calculation) but the probability is low. The lack of calculation in the gallbladder will cause to search for anotherobstruction and bile stasis and in particular a tumor of the ampullary region or a non-biliary disease.
When gallstones are found on ultrasound, the radiologist will work to find a dilated intrahepatic bile ducts and extrahepatic, as far as the common hepatic duct at the junction of the hepatic artery should be performed accurately.
Then there is an expansion or not, the ultrasound will seek insistently a calculation of the lower bile duct. For this it is essential to help positional maneuvering to use the patient's inspiratory variations to identify the portion retro-pancreatic and peri-ampullary lower bile duct. The poor sensitivity of ultrasound does not eliminate the diagnosis of calculation of the common bile duct when it is negative.
Evidence from ultrasound (presence of gallstones, any signs of cholecystitis, dilation of the bile duct) will assist the clinician in conjunction with clinical and laboratory data to determine whether the acute, painful, the patient is related to a problem or not gallstone migration.
Many scores can be calculated from the ultrasound data, biological and clinical. These scores generally reflect the age, the presence of gallstones less than 10 mm, a bile duct over 10 mm, a cholecystitis, to determine the likelihood of calculation of the common bile duct in preoperatively. Other scores combine ultrasound data to disturbances of liver function tests.
Quality standards, established by the learned societies of surgery in France, are expected to require the production of direct cholangiography (or intraoperative ultrasound) during cholecystectomy. If intraoperative cholangiography isactually carried out a systematic, research preoperative calculation of the common bile duct is not required.
This prevents the proliferation of pre-operative examinations when clinical, laboratory, and ultrasonographic characteristics are consistent and cholangitis in gallstone migration. Ultrasound is the imaging technique when necessary and sufficient for the exploration of patients with suspected cholangitis.
But when clinical and laboratory data are not typical, that patients are not echogenic, or intraoperative cholangiography is not perfectly controlled and / or systematically destroyed by the surgical team, a precise morphological exploration of the way preoperative biliary required. Cholangiography by MRI at this stage considering the most effective non-invasive.
In severe forms immediately, the realization of a scanner with an emergency acquisition without and after injection of iodine in the absence of renal failure is entirely lawful.
CT easily detect complications (pylephlebitis, abscess, pancreatitis) or catch an incorrect clinical diagnosis by demonstrating an alternative diagnosis.
History of cholecystectomy
In patients with a history of cholecystectomy, the problem is very different, since the pre-treatment examinations should determine whether the patient should be given whether or not a retrograde cholangiopancreatography with sphincterotomy.
The significant risk of such treatment (pancreatitis, infectious complications, hemorrhagic complications of sphincterotomy) justifies the existence of one or more calculations the common bile duct are formally individualized to indicate that gesture.
If the ultrasound does not reveal a stone in the common bile duct, other imaging investigations are needed. In subjects not echogenic, and when we could not adequately explore the common bile duct and common bile duct, the realization of a CT scan is a simple and rapid method which allows in some cases to confirm the existence of a calculation. However, examination of reference in this circumstance are MR cholangiography and endoscopic ultrasonography.
The endoscopic ultrasonography offers the advantage of being performed immediately before ERCP possible which will be indicated if endoscopic ultrasonography found a calculation. This is the strategy to be adopted for calculating the suspicion is strong.
On the contrary, the suspicion of calculation is lower, it is preferable to perform MRI cholangiography much less invasive, although its sensitivity is slightly worse than the echo-endoscopy eliminates a great value negative predictive diagnosis for calculating the bile duct.
History of surgery for bile duct
The latter circumstance for patients with a history of surgery of the bile duct and in particular of biliary-digestive anastomosis.
In these patients, cholangitis occur in an atypical way and are not necessarily linked to the presence of gallstones, but most often due to stenosis of the biliary-digestive anastomosis. Calculations, when present, follow the bile stasis and chronic infection that favor the formation of intraductal material.
If cholangitis, patients have a table overlooking infectious, often severe, with septicemia associated with cytolysis and anicteric cholestasis or not. The pain is often rough at times kind of heaviness in the right hypochondrium.
Ultrasound, which must be performed as first-line, not always found in bile duct dilatation, strictures, or because sometimes incomplete. Cholangiography by MRI has become the gold standard for exploring this type of patient.
It allows precise mapping of the bile ducts above the anastomosis and anastomotic. It is essential for any therapeutic decision, whether further surgery or percutaneous biliary drainage.
08:55
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