PROGNOSIS OF cholangitis
Mortality of cholangitis is high, especially if left untreated and in people who have associated defects, the literature reports a mortality rate of about 7 to 40%.
The prognosis of cholangitis depends on several factors:
Epidemiological factors:
Age, sex, associated defects, obesity ....
The type of cholangitis:
In cholangitis initially uncomplicated, the mortality rate is significantly low.
If cholangitis complicated, the prognosis is often put into play and the mortality is very high.
The severity of the prognosis of cholangitis is made of multiple causes, they are either occurred in the immediate postoperative acute pancreatitis, bile peritonitis, gastrointestinal bleeding, or recurrence of septic phenomena, of kidney failure; but they can also be the result of actions taken or operating poorly local adverse operating conditions, or the cause of cholangitis itself as in the case of neoplasia.
The following factors are associated with a high degree of morbidity and mortality:
- Female.
- Age> 50 years.
- Hypotension.
- Kidney failure.
- The abscess of the liver.
- Cirrhosis.
- The radiological cholangitis (post percutaneous cholangiography).
- Lack of response to antibiotics and medical treatment.
- Extension of time to decompress the bile ducts.
The prognosis of cholangitis depends on several factors:
Epidemiological factors:
Age, sex, associated defects, obesity ....
The type of cholangitis:
In cholangitis initially uncomplicated, the mortality rate is significantly low.
If cholangitis complicated, the prognosis is often put into play and the mortality is very high.
The severity of the prognosis of cholangitis is made of multiple causes, they are either occurred in the immediate postoperative acute pancreatitis, bile peritonitis, gastrointestinal bleeding, or recurrence of septic phenomena, of kidney failure; but they can also be the result of actions taken or operating poorly local adverse operating conditions, or the cause of cholangitis itself as in the case of neoplasia.
The following factors are associated with a high degree of morbidity and mortality:
- Female.
- Age> 50 years.
- Hypotension.
- Kidney failure.
- The abscess of the liver.
- Cirrhosis.
- The radiological cholangitis (post percutaneous cholangiography).
- Lack of response to antibiotics and medical treatment.
- Extension of time to decompress the bile ducts.
09:13 | | 0 Comments
THERAPEUTIC STRATEGY
There is no consensus regarding the treatment of cholangitis ....
> Although it is widely regarded as the ideal treatment is based on laparoscopic surgery at a time, including cholecystectomy, intraoperative cholangiography and stone extraction. In this situation, so there is no room for endoscopic treatment.
> However, in centers where surgeons are experienced in the practice of comprehensive treatment of cholangitis in laparoscopy, cholecystectomy is performed only by laparoscopy, and treated the calculations of the VBP by endoscopy.
Several choices are possible:
- Either we make the first endoscopic approach, possibly including sphincterotomy, with its risks (morbidity of 8 to 10% and mortality of 0.2% on average, up 1.5% for oddienne complication) and a failure rate of about 4 to 6%, followed by laparoscopic cholecystectomy.
- Or, and this seems preferable, it begins with laparoscopic cholecystectomy with placement of a transcystic drain, secondarily, a cholangiogram is performed by the drain and the presence of the calculation has been confirmed, we slide a wire - guide the drain to conduct endoscopic sphincterotomy with minimal risk. In this protocol, the success rate is close to 100%.
Complications of sphincterotomy are represented mostly by acute pancreatitis (early pancreatic purely biological reaction to a pancreatic reaction requiring several days of hospitalization, or to severe forms with a very serious risk of death), followed by the bleeding and fewer duodenal perforation, peri-ampullary, retroperitoneal.
> A final indication of the endoscopic approach arises when the surgery was originally scheduled to be complete in time, is in check because of the excessive size of the calculation or the presence of a duodenal diverticulum or peri-choledochal of treatment failure of the bile duct. In this case, after cholecystectomy, transcystic drain is allowed and the following week, the endoscopist will complete the surgery.
If cons-indication for surgery, it is limited to the endoscopic treatment, leaving the gallbladder in place.
> Finally, surgery by treaty will be the only indication to the inability or failure of laparoscopic and endoscopic techniques.
> Surgery by treaty will be the only indication to the inability or failure of laparoscopic and endoscopic techniques.
> Although it is widely regarded as the ideal treatment is based on laparoscopic surgery at a time, including cholecystectomy, intraoperative cholangiography and stone extraction. In this situation, so there is no room for endoscopic treatment.
> However, in centers where surgeons are experienced in the practice of comprehensive treatment of cholangitis in laparoscopy, cholecystectomy is performed only by laparoscopy, and treated the calculations of the VBP by endoscopy.
Several choices are possible:
- Either we make the first endoscopic approach, possibly including sphincterotomy, with its risks (morbidity of 8 to 10% and mortality of 0.2% on average, up 1.5% for oddienne complication) and a failure rate of about 4 to 6%, followed by laparoscopic cholecystectomy.
- Or, and this seems preferable, it begins with laparoscopic cholecystectomy with placement of a transcystic drain, secondarily, a cholangiogram is performed by the drain and the presence of the calculation has been confirmed, we slide a wire - guide the drain to conduct endoscopic sphincterotomy with minimal risk. In this protocol, the success rate is close to 100%.
Complications of sphincterotomy are represented mostly by acute pancreatitis (early pancreatic purely biological reaction to a pancreatic reaction requiring several days of hospitalization, or to severe forms with a very serious risk of death), followed by the bleeding and fewer duodenal perforation, peri-ampullary, retroperitoneal.
> A final indication of the endoscopic approach arises when the surgery was originally scheduled to be complete in time, is in check because of the excessive size of the calculation or the presence of a duodenal diverticulum or peri-choledochal of treatment failure of the bile duct. In this case, after cholecystectomy, transcystic drain is allowed and the following week, the endoscopist will complete the surgery.
If cons-indication for surgery, it is limited to the endoscopic treatment, leaving the gallbladder in place.
> Finally, surgery by treaty will be the only indication to the inability or failure of laparoscopic and endoscopic techniques.
> Surgery by treaty will be the only indication to the inability or failure of laparoscopic and endoscopic techniques.
09:12 | | 0 Comments
OTHER THERAPEUTIC METHODS IN cholangitis
Intraoperative sphincterotomy
This method will call the surgeon in addition to the skills of an endoscope. This treatment strategy was apparently associated with it an unusual pancreatic disease.
stents
An alternative to external biliary drainage to prevent postoperative biliary loss; It involves placing a stent during surgery transpapillary bile duct, it will be removed secondarily by endoscopy from 15 to 21 days later.
This method will call the surgeon in addition to the skills of an endoscope. This treatment strategy was apparently associated with it an unusual pancreatic disease.
stents
An alternative to external biliary drainage to prevent postoperative biliary loss; It involves placing a stent during surgery transpapillary bile duct, it will be removed secondarily by endoscopy from 15 to 21 days later.
09:10 | | 0 Comments
Postoperative Cholangitis
Monitoring postoperative general and local depends on the technique used.
In the event of a transcystic or choledochotomy closure primitive, it is considered that the certainty of the emptiness of the VBP was acquired, no exploration bladder is a priori justified, monitoring of liver suction drain in the absence of any checks bile leakage.
The presence of postoperative external biliary drain justify specific surveillance, the first thing to look at it is its speed:
- If the flow is low, check that it is not bent, its attachment to the skin is not too tight and there is no bile leak in the suction drain.
In doubt and if the clinical or laboratory evidence suggest it: Pain, fever, disruption of biological tests must hasten cholangiographic control to check that the drain is in place, moving the drain is an indication of further surgery.
- If the flow rate and significant above 600 or 700 ml/24h must evoke a barrier downstream and primarily a residual calculation, the diagnosis is made by cholangiography.
The importance of the leak can be quickly metabolic consequences (dehydration, leakage of sodium and bicarbonates) which are matched by contributions preventive oral or IV.
Cholangiography control by external biliary drainage is systematic, it shall be made 3-4 days after surgery, the absence of anomalies in the latter allows the clamping of the drain after 24 hours.
The patient will be kept for another 12 to 24 hours in surveillance to ensure tolerance: absence of biliary-type pain and fever.
The drain will be removed as an outpatient within 03 weeks.
In the event of a transcystic or choledochotomy closure primitive, it is considered that the certainty of the emptiness of the VBP was acquired, no exploration bladder is a priori justified, monitoring of liver suction drain in the absence of any checks bile leakage.
The presence of postoperative external biliary drain justify specific surveillance, the first thing to look at it is its speed:
- If the flow is low, check that it is not bent, its attachment to the skin is not too tight and there is no bile leak in the suction drain.
In doubt and if the clinical or laboratory evidence suggest it: Pain, fever, disruption of biological tests must hasten cholangiographic control to check that the drain is in place, moving the drain is an indication of further surgery.
- If the flow rate and significant above 600 or 700 ml/24h must evoke a barrier downstream and primarily a residual calculation, the diagnosis is made by cholangiography.
The importance of the leak can be quickly metabolic consequences (dehydration, leakage of sodium and bicarbonates) which are matched by contributions preventive oral or IV.
Cholangiography control by external biliary drainage is systematic, it shall be made 3-4 days after surgery, the absence of anomalies in the latter allows the clamping of the drain after 24 hours.
The patient will be kept for another 12 to 24 hours in surveillance to ensure tolerance: absence of biliary-type pain and fever.
The drain will be removed as an outpatient within 03 weeks.
09:09 | | 0 Comments
DIFFERENTIAL DIAGNOSIS OF cholangitis
CholecystitisIt
corresponds to an inflammation and infection of the gallbladder, the
pain is like a colic but it is very acute, almost always accompanied by a
defense of the right upper quadrant and especially fever, jaundice is
rare, biologically ,
disturbances are moderate liver, ultrasound allows the diagnosis by
showing wall thickening and gallbladder distention often associated with
pain in passing characteristic of the probe (ultrasonographic Murphy's
sign) and the absence of bile duct dilatation .
Mirizzi SYNDROMEMirizzi syndrome is a rare complication of gallstones in relation to an extrinsic compression of the bile duct by a calculus impacted in the infundibulum and the cystic duct.Ultrasonography may be misleading objectifying dilatation of the bile ducts inside and outside the liver with suspicion of common bile duct stones at the bottom.The diagnostic confirmation will be placed intraoperatively by finding a gallbladder lithiasis with sometimes large landlocked calculations in very dilated cystic compressing the common bile duct. This is free as will show the intra-operative cholangiography and cholédocoscopie.
THE BILIARY PANCREATITISIt is due to the isolation of a calculation at the ampulla of Vater, which will result in:
* An increase in pressure in the pancreatic duct (Wirsung The).
* Reflux of bile into the same channel.
* Activation of pancreatic enzymes.
* Inflammatory reaction.
It has the same clinical picture as cholangitis, the diagnosis is made by:The determination of amylase and amylase to be superior to 3 times normal.Ultrasound has no interest, visualization of the pancreas is difficult and may not be possible in 45-60% of cases, it will visualize especially gallstones (etiologic diagnosis).Chronic active hepatitis (ESP C)In cholestatic form, indeed, in some patients, chronic active hepatitis causes a marked cholestasis with jaundice more or less intense itching with increased PAL, sometimes permanent cholestasis is dominating the clinical picture that looks to quite near to primary biliary cirrhosis, cholestasis sometimes occurs in periods, accompanying the exacerbations of chronic active hepatitis. Serology confirmed the diagnosis.PERFORATION OR TORSION of the gallbladder
Mirizzi SYNDROMEMirizzi syndrome is a rare complication of gallstones in relation to an extrinsic compression of the bile duct by a calculus impacted in the infundibulum and the cystic duct.Ultrasonography may be misleading objectifying dilatation of the bile ducts inside and outside the liver with suspicion of common bile duct stones at the bottom.The diagnostic confirmation will be placed intraoperatively by finding a gallbladder lithiasis with sometimes large landlocked calculations in very dilated cystic compressing the common bile duct. This is free as will show the intra-operative cholangiography and cholédocoscopie.
THE BILIARY PANCREATITISIt is due to the isolation of a calculation at the ampulla of Vater, which will result in:
* An increase in pressure in the pancreatic duct (Wirsung The).
* Reflux of bile into the same channel.
* Activation of pancreatic enzymes.
* Inflammatory reaction.
It has the same clinical picture as cholangitis, the diagnosis is made by:The determination of amylase and amylase to be superior to 3 times normal.Ultrasound has no interest, visualization of the pancreas is difficult and may not be possible in 45-60% of cases, it will visualize especially gallstones (etiologic diagnosis).Chronic active hepatitis (ESP C)In cholestatic form, indeed, in some patients, chronic active hepatitis causes a marked cholestasis with jaundice more or less intense itching with increased PAL, sometimes permanent cholestasis is dominating the clinical picture that looks to quite near to primary biliary cirrhosis, cholestasis sometimes occurs in periods, accompanying the exacerbations of chronic active hepatitis. Serology confirmed the diagnosis.PERFORATION OR TORSION of the gallbladder
09:01 | | 0 Comments
EVOLUTION OF CHOLANGITIS
It can be positive and transient, moving so regressive, either spontaneously or under treatment.
But this favorable access without prejudice to the subsequent development, the appearance of recurrences may themselves give rise rapidly to serious complications, will indeed be based on the persistence or not of the obstacle and causal nature of the obstacle.
COMPLICATIONS
Early complications
Complications related to the onset of sepsis:
Gram-negative sepsis
Sepsis is characterized by significant and repeated shocks in the blood of pathogens from an outbreak of some kind.
Sepsis is likely to cause secondary outbreaks that will multiply more or less apparent.
Clinically it results:
* High fever which is the presence of bacteria in large numbers in the blood.
* Drop in blood pressure.
* Face greyish.
* Cold extremities.
* Tachycardia.
* Signs indicating a disorder of blood coagulation.
* Chills, asthenia.
* Malaysia, Splenomegaly.
* Difficulty breathing.
The diagnosis is confirmed by the laboratory through which a blood culture and determination of an effective antibiotic (for sensitivity) is made at the time of fever spikes. The appearance of multiple visceral involvement, has in some cases to confirm the clinical diagnosis.Finally, a septic shock endotoxin may be, with:
* Events kidney.
* Cardiovascular collapse.
* Hemorrhagic Syndrome.
* Centro lobular hepatic necrosis.
* Acute edematous pancreatitis or nérotico colitis.
The renal manifestations
Encompasses a range of syndrome of varying severity, ranging from simple functional renal failure in renal organic. These renal failure occur more readily in subjects with multiple defects, and those with a long history of bladder.
Clinically: it generally does not change the little picture of cholangitis:
* Jaundice, however, can change the type and take a look flamboyant.
* Hypotension is common.
Own signs of kidney disease (anorexia, nausea, vomiting, drowsiness, impaired consciousness), are difficult to distinguish from those of cholangitis.
In practice, it should be distinguished:
The benign forms: usually corresponding to functional renal failure with oliguria, urinary urea concentration is high, but creatinine is normal. They cause dehydration with hydro electrolytic disorders, but are reversible after fluid replacement and / or hydro electrolytic rebalancing.
Serious: with oligo anuria, diuresis or retained, but with azotemia and creatinine still high, and the significant decrease in urinary urea concentration.The cardiovascular collapse
Installation is quick and brutal, manifested clinically by:
- A fall in blood pressure.
- Tachycardia.
- A fast breathing.
- A fall in central venous pressure.
- Oliguria.
Sometimes profuse diarrhea and vomiting sometimes bleeding.
The hemorrhagic syndrome
With mucocutaneous bleeding, or hematemesis, or melena alone. GI bleeding in this case, is often related to stress peptic ulcers, the occurrence of disseminated intravenous coagulation aggravates the bleeding.
Loco regional complications
Extension of the inflammatory process and infection with various elements of the hepatic pedicle:Relatively frequent local complications (20% of cases), may pose difficult surgical problems, pédiculite this is seen especially in patients subjected to prolonged antibiotic therapy, for which the time of surgery was delayed.
Liver abscesses:Are the result of direct spread of infection, but may be the result of localization of metastatic sepsis.
Miliary abscesses:Are the most frequent single abscess is rarer, likely to surgical drainage.
Pédiculites and abscesses:Can cause internal fistula generally, and perforations in the peritoneum free or partitioned, they are difficult to diagnose.
Late Complications
Sclerosing cholangitis and secondary
They are usually defined as disorders of the biliary tract acquired, non-tumor, diffuse or multifocal. They are generally characterized by irregularities in caliber of the bile duct strictures and dilatations involving. The inflammatory and sclerosing character is more often inferred from the radiological appearance as shown by histological examination.
The secondary cholangitis should be distinguished from a primary sclerosing cholangitis, and other aspects of irregular bile ducts caused by a tumor, or a breach of the light of the bile ducts more than that of their wall.
Clinically it results:
* An intermittent obstructive jaundice.
* A fever.
* A gradual decline in general health.
The opacification of the biliary tree is used to specify the characteristics of this cholangitis, there are then:
- Strictures localized only to the extra hepatic bile duct, raises the differential diagnosis with post-traumatic stenosis.- Strictures localized only to intra hepatic or biliary dilatation, raises the differential diagnosis with congenital stenosis of the bile ducts within the liver.
The disease progresses to chronic retention that can lead to secondary biliary cirrhosis.Sclerosing cholangitis secondary to group together a large number of bile with very rare.
It is convenient to classify these patients into three groups: those whose ischemic origin is certain, those with ischemic possible; bile and other injuries.
The secondary biliary cirrhosis
Its starting point is the element responsible for initial obstructive cholangitis, plus the development of secondary sclerosing cholangitis, which causes a chronic progressive cholestasis.
According to "Scobie" and "Summerskill," the surgical wounds of the biliary tract are the main etiology in the case of repeated cholangitis preceding cirrhosis.The clinical picture is not specific, as the pathology, diagnosis is based primarily on the history and the discovery of obstruction.
But this favorable access without prejudice to the subsequent development, the appearance of recurrences may themselves give rise rapidly to serious complications, will indeed be based on the persistence or not of the obstacle and causal nature of the obstacle.
COMPLICATIONS
Early complications
Complications related to the onset of sepsis:
Gram-negative sepsis
Sepsis is characterized by significant and repeated shocks in the blood of pathogens from an outbreak of some kind.
Sepsis is likely to cause secondary outbreaks that will multiply more or less apparent.
Clinically it results:
* High fever which is the presence of bacteria in large numbers in the blood.
* Drop in blood pressure.
* Face greyish.
* Cold extremities.
* Tachycardia.
* Signs indicating a disorder of blood coagulation.
* Chills, asthenia.
* Malaysia, Splenomegaly.
* Difficulty breathing.
The diagnosis is confirmed by the laboratory through which a blood culture and determination of an effective antibiotic (for sensitivity) is made at the time of fever spikes. The appearance of multiple visceral involvement, has in some cases to confirm the clinical diagnosis.Finally, a septic shock endotoxin may be, with:
* Events kidney.
* Cardiovascular collapse.
* Hemorrhagic Syndrome.
* Centro lobular hepatic necrosis.
* Acute edematous pancreatitis or nérotico colitis.
The renal manifestations
Encompasses a range of syndrome of varying severity, ranging from simple functional renal failure in renal organic. These renal failure occur more readily in subjects with multiple defects, and those with a long history of bladder.
Clinically: it generally does not change the little picture of cholangitis:
* Jaundice, however, can change the type and take a look flamboyant.
* Hypotension is common.
Own signs of kidney disease (anorexia, nausea, vomiting, drowsiness, impaired consciousness), are difficult to distinguish from those of cholangitis.
In practice, it should be distinguished:
The benign forms: usually corresponding to functional renal failure with oliguria, urinary urea concentration is high, but creatinine is normal. They cause dehydration with hydro electrolytic disorders, but are reversible after fluid replacement and / or hydro electrolytic rebalancing.
Serious: with oligo anuria, diuresis or retained, but with azotemia and creatinine still high, and the significant decrease in urinary urea concentration.The cardiovascular collapse
Installation is quick and brutal, manifested clinically by:
- A fall in blood pressure.
- Tachycardia.
- A fast breathing.
- A fall in central venous pressure.
- Oliguria.
Sometimes profuse diarrhea and vomiting sometimes bleeding.
The hemorrhagic syndrome
With mucocutaneous bleeding, or hematemesis, or melena alone. GI bleeding in this case, is often related to stress peptic ulcers, the occurrence of disseminated intravenous coagulation aggravates the bleeding.
Loco regional complications
Extension of the inflammatory process and infection with various elements of the hepatic pedicle:Relatively frequent local complications (20% of cases), may pose difficult surgical problems, pédiculite this is seen especially in patients subjected to prolonged antibiotic therapy, for which the time of surgery was delayed.
Liver abscesses:Are the result of direct spread of infection, but may be the result of localization of metastatic sepsis.
Miliary abscesses:Are the most frequent single abscess is rarer, likely to surgical drainage.
Pédiculites and abscesses:Can cause internal fistula generally, and perforations in the peritoneum free or partitioned, they are difficult to diagnose.
Late Complications
Sclerosing cholangitis and secondary
They are usually defined as disorders of the biliary tract acquired, non-tumor, diffuse or multifocal. They are generally characterized by irregularities in caliber of the bile duct strictures and dilatations involving. The inflammatory and sclerosing character is more often inferred from the radiological appearance as shown by histological examination.
The secondary cholangitis should be distinguished from a primary sclerosing cholangitis, and other aspects of irregular bile ducts caused by a tumor, or a breach of the light of the bile ducts more than that of their wall.
Clinically it results:
* An intermittent obstructive jaundice.
* A fever.
* A gradual decline in general health.
The opacification of the biliary tree is used to specify the characteristics of this cholangitis, there are then:
- Strictures localized only to the extra hepatic bile duct, raises the differential diagnosis with post-traumatic stenosis.- Strictures localized only to intra hepatic or biliary dilatation, raises the differential diagnosis with congenital stenosis of the bile ducts within the liver.
The disease progresses to chronic retention that can lead to secondary biliary cirrhosis.Sclerosing cholangitis secondary to group together a large number of bile with very rare.
It is convenient to classify these patients into three groups: those whose ischemic origin is certain, those with ischemic possible; bile and other injuries.
The secondary biliary cirrhosis
Its starting point is the element responsible for initial obstructive cholangitis, plus the development of secondary sclerosing cholangitis, which causes a chronic progressive cholestasis.
According to "Scobie" and "Summerskill," the surgical wounds of the biliary tract are the main etiology in the case of repeated cholangitis preceding cirrhosis.The clinical picture is not specific, as the pathology, diagnosis is based primarily on the history and the discovery of obstruction.
08:59 | | 0 Comments
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 | | 0 Comments
Clinical forms of cholangitis
Asymptomatic
The asymptomatic discovery when one operates (during surgery) for gallstones (cholecystectomy), cholangitis in this case can evolve sue a less evocative, the discovery is obviously more difficult especially in the absence of background Bile known [8].
Crude form or LATENT
It is rare but possible. There are few clinical signs are mainly in the elderly. However, even latent, this will require a quick movement cholangitis because of complications may be very brutal.
The latent cholangitis may express itself violently, during an outbreak of acute gallstone disease, or in various circumstances:
- Opacification instrumental biliary tract.
- Endoscopic sphincterotomy.
- Common duct endoscopy.
- Explorations intraoperative manometric.
Symptomatic forms
- Forms purely painful.
- Pure febrile forms.
- Forms icteric pure.
Complicated shape, "cholangitis ACUTE icterus UREMIGENE"
- Fortunately rare, but always fear, she realizes a typical picture of cholangitis but is, in the hours and the maximum in the next few days, accompanied by a severe septic shock that goes largely to the fore, combining in one period very short renal organic. Age greater than 70 is an additional factor of gravity.
Clinically:
It jaundice installation very fast and becomes very intense, says "flamboyant".
- Signs of toxic shock infectious.
- And the rapid onset renal organic (oliguria).
- Sometimes disorders of consciousness (delirium).
Biologically:
- Thrombocytopenia <150,000 mm3.
- Direct bilirubin can be> 400 micromol / l.
- Increase in blood urea> 20 mmol / l and creatinine> 110 mmol / l.
- Hyperkalemia dangerous above 6 mEq / l.
- Acidosis (retention of H + ions which are not eliminated).
This is an emergency treatment will require unblocking the bile duct and eventually hemodialysis.
The asymptomatic discovery when one operates (during surgery) for gallstones (cholecystectomy), cholangitis in this case can evolve sue a less evocative, the discovery is obviously more difficult especially in the absence of background Bile known [8].
Crude form or LATENT
It is rare but possible. There are few clinical signs are mainly in the elderly. However, even latent, this will require a quick movement cholangitis because of complications may be very brutal.
The latent cholangitis may express itself violently, during an outbreak of acute gallstone disease, or in various circumstances:
- Opacification instrumental biliary tract.
- Endoscopic sphincterotomy.
- Common duct endoscopy.
- Explorations intraoperative manometric.
Symptomatic forms
- Forms purely painful.
- Pure febrile forms.
- Forms icteric pure.
Complicated shape, "cholangitis ACUTE icterus UREMIGENE"
- Fortunately rare, but always fear, she realizes a typical picture of cholangitis but is, in the hours and the maximum in the next few days, accompanied by a severe septic shock that goes largely to the fore, combining in one period very short renal organic. Age greater than 70 is an additional factor of gravity.
Clinically:
It jaundice installation very fast and becomes very intense, says "flamboyant".
- Signs of toxic shock infectious.
- And the rapid onset renal organic (oliguria).
- Sometimes disorders of consciousness (delirium).
Biologically:
- Thrombocytopenia <150,000 mm3.
- Direct bilirubin can be> 400 micromol / l.
- Increase in blood urea> 20 mmol / l and creatinine> 110 mmol / l.
- Hyperkalemia dangerous above 6 mEq / l.
- Acidosis (retention of H + ions which are not eliminated).
This is an emergency treatment will require unblocking the bile duct and eventually hemodialysis.
08:51 | | 0 Comments
Biological and bacteriological at cholangitis
Biology:
FNS (Formula Blood Count)
A small-anemia without any particular characteristic.-A significant rise in white blood cells (WBC)> 15,000 éléments/mm3 in neutrophils (75-90%).
Liver
Highlights syndrome retentional.An honest-bilirubin increased predominantly combined (up to 10 times the normal value).-Presence of bile pigments in urine.-A persistent increase in alkaline phosphatase.-An increase of 5 'nucleotidases and GGT (no limit).-An increase in transaminases (SGOT, SGPT) to 5 to 10 times the normal value.-A decrease in the absorption of the assimilation of vitamin K which results in a decrease in the prothrombin time (blood clotting disorders).-An increase in CRP and fibrinogen is due which are markers indicating that there is inflammation, they ride in the days following the crisis with increased alpha2 and gamma globulins.
Bacteriology
In terms of bacteriological removal of bile in patients with cholangitis usually contains more than 100,000 cells / ml composed of two or more seeds. This percentage is even higher if:
- Fever above 39 ° C.- Shock.- Neuropsychiatric disorders.- Leucocytosis> 10,000.
The seeds are usually blood similar to those found in bile and are of intestinal origin. The germs most frequently found are Gram-negative bacilli (GNB), cocci gram (+), anaerobes responsible for severe sepsis.
Bacteria include the most common acute cholangitis lithiasis:
Gram-negative bacilli (60% to 80%):
- E. Coli.- Klebsiella pneumonia.- Pseudomonas aeruginosa.- Enterobacter cloacae.- Proteus morganii.
Gram-positive cocci (20% to 30%):
- Streptococcus faecalis.- Staphylococcus aureus.- Other types of streptococcus.
Anaerobic: 40%:
- Bacteroides fragilis.- Clostridium perfingens.- Especially if biliodigestives anastomoses.- Demonstration severe sepsis.- Postoperative septic complications.
FNS (Formula Blood Count)
A small-anemia without any particular characteristic.-A significant rise in white blood cells (WBC)> 15,000 éléments/mm3 in neutrophils (75-90%).
Liver
Highlights syndrome retentional.An honest-bilirubin increased predominantly combined (up to 10 times the normal value).-Presence of bile pigments in urine.-A persistent increase in alkaline phosphatase.-An increase of 5 'nucleotidases and GGT (no limit).-An increase in transaminases (SGOT, SGPT) to 5 to 10 times the normal value.-A decrease in the absorption of the assimilation of vitamin K which results in a decrease in the prothrombin time (blood clotting disorders).-An increase in CRP and fibrinogen is due which are markers indicating that there is inflammation, they ride in the days following the crisis with increased alpha2 and gamma globulins.
Bacteriology
In terms of bacteriological removal of bile in patients with cholangitis usually contains more than 100,000 cells / ml composed of two or more seeds. This percentage is even higher if:
- Fever above 39 ° C.- Shock.- Neuropsychiatric disorders.- Leucocytosis> 10,000.
The seeds are usually blood similar to those found in bile and are of intestinal origin. The germs most frequently found are Gram-negative bacilli (GNB), cocci gram (+), anaerobes responsible for severe sepsis.
Bacteria include the most common acute cholangitis lithiasis:
Gram-negative bacilli (60% to 80%):
- E. Coli.- Klebsiella pneumonia.- Pseudomonas aeruginosa.- Enterobacter cloacae.- Proteus morganii.
Gram-positive cocci (20% to 30%):
- Streptococcus faecalis.- Staphylococcus aureus.- Other types of streptococcus.
Anaerobic: 40%:
- Bacteroides fragilis.- Clostridium perfingens.- Especially if biliodigestives anastomoses.- Demonstration severe sepsis.- Postoperative septic complications.
08:49 | | 0 Comments
Diagnosis of Cholangitis
This
condition expresses itself in the form of a table that is scalable,
beginning with Charcot's triad that is made of three symptoms: pain,
fever with chills and jaundice moderate. What characterizes them is their association as well as their chronology [18].
Charcot's triad: (~ 70%)
Pain (50-90%)
It precedes a fever a few hours, it reflects the sudden tensioning of the bile duct. It is a little different colic pain, it is lively, situated in the right hypochondrium, with irradiation dorsal and anterior and posterior chest.
Although it is usually epigastric, usually more prolonged and less paroxysmal. Sometimes it is atypical, and may be limited to a simple weight of the right upper quadrant, or even absent.
Acute liver pain must fear the formation of an abscess within the liver.
Fever (90-95%)
It is always present, it means the infection of the bile ducts and discharge bacteremia, why should be performed immediately blood cultures for isolating the causative organism.
It occurs within hours of pain and changes in access pseudo-marsh, made of a succession of major peaks, more or less frequently repeated in the nycthemeron, accompanied by chills, it amounts to a temperature: 40 ° c to 41 ° C, ending with an abrupt defervescence accompanied by sweating between the febrile attacks there remains a sub febrile state.
Jaundice: (60-80%)
It appears from 12 to 48 hours, at most, it is progressive, variable intensity, ranging from a simple sub conjunctival jaundice jaundice mucocutaneous, with coloration of urine and stool discoloration and itching.
In some cases, jaundice may precede fever, which can be an argument for referral to a neoplastic etiology of chronic obstacle or not.
The pentad of REYNOLDS: (5-10%)
It involves, in addition to Charcot's triad, two signs:
- Septic shock.- Mental confusion and / or lethargy.
It is seen especially in the elderly and it is poor prognosis.
General symptoms
It should be understood in fact, that cholangitis is sepsis.The occurrence of cholangitis access leads to greater or lesser impact on the general, it is often noted for signs that may herald the onset of a severe form:
* Alteration facies.
* Acceleration of the pulse.
* Small drop in blood pressure.
* Tachypnea.
* Gastrointestinal disorders: nausea, vomiting.
* Oliguria with dark urine.
The examination
- It searches the notion of a known stone disease, history of jaundice, painful episodes of right flank or febrile episodes.
The physical examination
Clinical examination is generally poor, the palpation of right upper quadrant pain majorises (Murphy's sign), sometimes there is a moderate hepatomegaly. The liver is more or less painful, rarely can feel a big gall tense.
The presence of a defense and a contracture localized or generalized throughout the abdomen, resulting peritoneal involvement.
Charcot's triad: (~ 70%)
Pain (50-90%)
It precedes a fever a few hours, it reflects the sudden tensioning of the bile duct. It is a little different colic pain, it is lively, situated in the right hypochondrium, with irradiation dorsal and anterior and posterior chest.
Although it is usually epigastric, usually more prolonged and less paroxysmal. Sometimes it is atypical, and may be limited to a simple weight of the right upper quadrant, or even absent.
Acute liver pain must fear the formation of an abscess within the liver.
Fever (90-95%)
It is always present, it means the infection of the bile ducts and discharge bacteremia, why should be performed immediately blood cultures for isolating the causative organism.
It occurs within hours of pain and changes in access pseudo-marsh, made of a succession of major peaks, more or less frequently repeated in the nycthemeron, accompanied by chills, it amounts to a temperature: 40 ° c to 41 ° C, ending with an abrupt defervescence accompanied by sweating between the febrile attacks there remains a sub febrile state.
Jaundice: (60-80%)
It appears from 12 to 48 hours, at most, it is progressive, variable intensity, ranging from a simple sub conjunctival jaundice jaundice mucocutaneous, with coloration of urine and stool discoloration and itching.
In some cases, jaundice may precede fever, which can be an argument for referral to a neoplastic etiology of chronic obstacle or not.
The pentad of REYNOLDS: (5-10%)
It involves, in addition to Charcot's triad, two signs:
- Septic shock.- Mental confusion and / or lethargy.
It is seen especially in the elderly and it is poor prognosis.
General symptoms
It should be understood in fact, that cholangitis is sepsis.The occurrence of cholangitis access leads to greater or lesser impact on the general, it is often noted for signs that may herald the onset of a severe form:
* Alteration facies.
* Acceleration of the pulse.
* Small drop in blood pressure.
* Tachypnea.
* Gastrointestinal disorders: nausea, vomiting.
* Oliguria with dark urine.
The examination
- It searches the notion of a known stone disease, history of jaundice, painful episodes of right flank or febrile episodes.
The physical examination
Clinical examination is generally poor, the palpation of right upper quadrant pain majorises (Murphy's sign), sometimes there is a moderate hepatomegaly. The liver is more or less painful, rarely can feel a big gall tense.
The presence of a defense and a contracture localized or generalized throughout the abdomen, resulting peritoneal involvement.
08:47 | | 0 Comments
Etiological studies of Cholangitis
The infection of the biliary tract is never primitive. It
occurs when bile stasis secondary to an incomplete obstruction of the
bile ducts outside the liver, more rarely in the affections of the bile
ducts within the liver and in cases of reflux of duodenal fluid in the
biliary tract.
And despite the wide variety of conditions that can lead to cholangitis, the etiology is clearly dominated by the gallstones [4] [41].
BARRIERS incomplete bile duct
Cholelithiasis
It is conceivable that, for there to be precipitation calculations, it is necessary that there be an absence of the solubilizing agent, bile salts, an excess of the substance to dissolve cholesterol.
This imbalance may have a food-borne because, in fact, gallstones is much more common in Europe and the Far East. But it is certain that these dietary factors are not the only culprits. There are probably circumstances where the rate of bile salts is insufficient.
Endocrine factors could cause such a change: the stones are more common in women and appears to be particularly favored by the pregnancy.
But in some cases very different, the stones due to excess bilirubin, a consequence of hemolysis: these are pigment stones.
Cholelithiasis is the main etiology of cholangitis, it is due to a calculation single or multiple calculations, they will favor infection.
Cholelithiasis
It is the stones of the bile duct, due mostly to calculations (calculation of the low - or riprap choledochal bile) is a common complication of lithiasis of the gallbladder, it may nevertheless occur outside any vesicular disease.
It is characterized clinically by the triad of Charcot pain, fever, with a dominant symptom as obstructive jaundice. The general condition is good at first, then eventually deteriorate.
The cholelithiasis is complicated:
- Liver failure and its corollary biliary cirrhosis.
- The suppurative cholangitis: suppuration of any large bile duct, which can create a true sepsis with renal disease (cholangitis urémigène).
Inflammatory strictures of the bile duct
Most often due to surgical trauma, usually during a cholecystectomy. The wound during surgery is unknown in most cases.
This is usually short stenosis who sit at the junction cystic duct - common bile duct.
These strictures post traumatic cause cholangitis in 64% of cases, or in the immediate postoperative, after several months or one year after the intervention.
Tumor of the ampulla of Vater
Stenosing papillitis
Pédiculite
THE CONDITIONS intrahepatic bile ducts
They are rare but must be known because they cause stasis and biliary infection.
Caroli's disease
Dysgenesis is a congenital intrahepatic bile duct, head of multifocal cystic dilations, it is associated in most cases with liver fibrosis.
More rarely, absence of liver fibrosis, the disease is so often localized to one part of the liver and can be accompanied by other congenital malformations of the bile duct (choledochal cyst).
Acquired and not congenital disease. Clinically it may be asymptomatic and discovered incidentally, bulletin recurrent cholangitis start between 5 and 30.
Biliary papillomatosis
It is a condition characterized by a papillary hyperplasia in continuous sheets of the lining of the bile ducts. Malignant degeneration is common, it is considered rare cause of cholangitis.
The intrahepatic gallstones
Are often providers of cholangitis, besides the existence of the latter, in this case is discussed.
Reflux of duodenal fluid in the biliary tract
It can be spontaneous, in the absence of any apparent stasis be due to:
Bilio-digestive fistulas spontaneous
They are usually progressive complications of gallstones, duodenal fistulae cholécysto-are the most common, but often less complicated than cholangitis-colic fistula cholécysto. The risk of cholangitis appears to be related mainly to the gene flow of bile.
May be due to some surgical procedures
Such as sphincterotomy and cholédoco-duodenal anastomoses that are responsible for reflux into the bile duct and cholangitis.
PARASITIC
In general they are associated with cholelithiasis:
Some parasites "fluke Fasciola hepatica in", "Ascaris lumbricoides" intraductal create a barrier.
Other parasites that tells "alveolar echinococcosis" or hydatid cyst, are responsible for compression. Note the possibility of migration of vesicles, girls or membranous debris in the bile duct, evidence of cracking of the cyst.
Note the special case of cholangitis in the Far East mostly due to a fluke "clonochis sinensis" cholangitis in this case is due to inflammatory strictures of the bile ducts within the liver inflammation by parasite.
The prognosis of cholangitis is usually dark.
Cholangitis RECURRENT PRIMITIVE
It is a disease of unknown etiology, met in the Far East, generally associated with intrahepatic stones, more rarely, a parasitic "Clonorchis sinensis."
CAUSES CANCER:
It is a less common cause is mainly quotes: cancer of the pancreatic head, ampullôme vaterien, cancer of the bile duct, or common bile duct. The prognosis of this type is particularly acute cholangitis.
The sclerotic odditis-CHRONIC PANCREATITIS
Are rare causes of cholangitis.
Iatrogenic Cholangitis
They are rare, and they are the price of progress in the techniques of opacification of the bile ducts, as well as non-surgical methods of intervention in the common bile duct.
Cholangiography by KEHR drain: cholangitis is caused by venous reflux cholangiopancreatography favored by intraductal pressure greater than 25 cm of water.
Cholangiography transparietal:The cholangitis is caused by a dual mechanism:
- Increased intraductal pressure during injection of contrast.
- Sowing the seeds by direct blood bile during transhepatic puncture.
The endoscopic retrograde cholangiopancreatography:Two conditions seem necessary to cause cholangitis, following a ERCP:
- Development of a pressure previously infected bile.
- Existence of a prior biliary obstruction.
Mirizzi SYNDROME
Mirizzi syndrome is a rare complication of gallstones in relation to an extrinsic compression of the bile duct by a calculus impacted in the infundibulum and the cystic duct [36].
OTHER CAUSES
They may be foreign, including foodborne, which are sometimes responsible for cholangitis.
And despite the wide variety of conditions that can lead to cholangitis, the etiology is clearly dominated by the gallstones [4] [41].
BARRIERS incomplete bile duct
Cholelithiasis
It is conceivable that, for there to be precipitation calculations, it is necessary that there be an absence of the solubilizing agent, bile salts, an excess of the substance to dissolve cholesterol.
This imbalance may have a food-borne because, in fact, gallstones is much more common in Europe and the Far East. But it is certain that these dietary factors are not the only culprits. There are probably circumstances where the rate of bile salts is insufficient.
Endocrine factors could cause such a change: the stones are more common in women and appears to be particularly favored by the pregnancy.
But in some cases very different, the stones due to excess bilirubin, a consequence of hemolysis: these are pigment stones.
Cholelithiasis is the main etiology of cholangitis, it is due to a calculation single or multiple calculations, they will favor infection.
Cholelithiasis
It is the stones of the bile duct, due mostly to calculations (calculation of the low - or riprap choledochal bile) is a common complication of lithiasis of the gallbladder, it may nevertheless occur outside any vesicular disease.
It is characterized clinically by the triad of Charcot pain, fever, with a dominant symptom as obstructive jaundice. The general condition is good at first, then eventually deteriorate.
The cholelithiasis is complicated:
- Liver failure and its corollary biliary cirrhosis.
- The suppurative cholangitis: suppuration of any large bile duct, which can create a true sepsis with renal disease (cholangitis urémigène).
Inflammatory strictures of the bile duct
Most often due to surgical trauma, usually during a cholecystectomy. The wound during surgery is unknown in most cases.
This is usually short stenosis who sit at the junction cystic duct - common bile duct.
These strictures post traumatic cause cholangitis in 64% of cases, or in the immediate postoperative, after several months or one year after the intervention.
Tumor of the ampulla of Vater
Stenosing papillitis
Pédiculite
THE CONDITIONS intrahepatic bile ducts
They are rare but must be known because they cause stasis and biliary infection.
Caroli's disease
Dysgenesis is a congenital intrahepatic bile duct, head of multifocal cystic dilations, it is associated in most cases with liver fibrosis.
More rarely, absence of liver fibrosis, the disease is so often localized to one part of the liver and can be accompanied by other congenital malformations of the bile duct (choledochal cyst).
Acquired and not congenital disease. Clinically it may be asymptomatic and discovered incidentally, bulletin recurrent cholangitis start between 5 and 30.
Biliary papillomatosis
It is a condition characterized by a papillary hyperplasia in continuous sheets of the lining of the bile ducts. Malignant degeneration is common, it is considered rare cause of cholangitis.
The intrahepatic gallstones
Are often providers of cholangitis, besides the existence of the latter, in this case is discussed.
Reflux of duodenal fluid in the biliary tract
It can be spontaneous, in the absence of any apparent stasis be due to:
Bilio-digestive fistulas spontaneous
They are usually progressive complications of gallstones, duodenal fistulae cholécysto-are the most common, but often less complicated than cholangitis-colic fistula cholécysto. The risk of cholangitis appears to be related mainly to the gene flow of bile.
May be due to some surgical procedures
Such as sphincterotomy and cholédoco-duodenal anastomoses that are responsible for reflux into the bile duct and cholangitis.
PARASITIC
In general they are associated with cholelithiasis:
Some parasites "fluke Fasciola hepatica in", "Ascaris lumbricoides" intraductal create a barrier.
Other parasites that tells "alveolar echinococcosis" or hydatid cyst, are responsible for compression. Note the possibility of migration of vesicles, girls or membranous debris in the bile duct, evidence of cracking of the cyst.
Note the special case of cholangitis in the Far East mostly due to a fluke "clonochis sinensis" cholangitis in this case is due to inflammatory strictures of the bile ducts within the liver inflammation by parasite.
The prognosis of cholangitis is usually dark.
Cholangitis RECURRENT PRIMITIVE
It is a disease of unknown etiology, met in the Far East, generally associated with intrahepatic stones, more rarely, a parasitic "Clonorchis sinensis."
CAUSES CANCER:
It is a less common cause is mainly quotes: cancer of the pancreatic head, ampullôme vaterien, cancer of the bile duct, or common bile duct. The prognosis of this type is particularly acute cholangitis.
The sclerotic odditis-CHRONIC PANCREATITIS
Are rare causes of cholangitis.
Iatrogenic Cholangitis
They are rare, and they are the price of progress in the techniques of opacification of the bile ducts, as well as non-surgical methods of intervention in the common bile duct.
Cholangiography by KEHR drain: cholangitis is caused by venous reflux cholangiopancreatography favored by intraductal pressure greater than 25 cm of water.
Cholangiography transparietal:The cholangitis is caused by a dual mechanism:
- Increased intraductal pressure during injection of contrast.
- Sowing the seeds by direct blood bile during transhepatic puncture.
The endoscopic retrograde cholangiopancreatography:Two conditions seem necessary to cause cholangitis, following a ERCP:
- Development of a pressure previously infected bile.
- Existence of a prior biliary obstruction.
Mirizzi SYNDROME
Mirizzi syndrome is a rare complication of gallstones in relation to an extrinsic compression of the bile duct by a calculus impacted in the infundibulum and the cystic duct [36].
OTHER CAUSES
They may be foreign, including foodborne, which are sometimes responsible for cholangitis.
08:45 | | 0 Comments
Cholangitis PATHOPHYSIOLOGY
In
most cases cholangitis is the result of a complete or incomplete
obstacle sitting on the CBD, but in some cases it occurs much more
expensive rare patients with CBD free [16].CHOLANGITIS WITH THE OBSTACLE OF CBDThree elements are involved in their development:- A complete or incomplete obstruction of the bile duct.- The penetration of pathogens in the CBD.- Factors promoting the spread of infection root canal.Damage to the VBPThis is the complete or incomplete obstruction of pathogens is critical. Stasis and dilation of the CBD are the result of obstruction and contribute to the development of infection.Penetration of germs in the CBDThe multiplicity of channels offered reflects their entanglement possible and ignorance of the exact mechanism.the way root canal bottom:Remains the most commonly accepted, but it is discussed. It is done by reflux of enteric bacteria and upstream stasis favors their multiplication.Thus the origin of intestinal bacteria isolated is a compelling argument in favor of this hypothesis. But the relative sterility of the duodenum is an objection to this theory.
hematogenously:It was suggested that the portal route involves the passage of intestinal bacteria in portal blood and bile back into the liver after treatment, but this mode of penetration of germs seems very questionable.the direct route:This mode of infection of the bile duct is now less often involved.It is the result of trauma infecting the bile ducts, mainly instrumental endoscopic maneuvers, and all surgery on the sphere hepatobiliary.Spread of infectionIs done in two ways:Local spread:Infection of the bladder directly responsible for the formation of abscesses in the walls of the bile ducts and liver parenchyma.Broadcast:Infectious process is done through blood, this blood-borne hypertension is facilitated by prevailing in VBP related to the existence of the obstacle.And several studies have demonstrated the existence of a reflux cholangioveineux bacteria on a blocked bile duct under pressure just above that of the hepatobiliary secretion.Moreover, whatever the mode of spread of infectious processes, terrain plays a supporting. Thus, cholangitis develops in a more severe in immunocompromised patients (treatment with corticosteroids and immunosuppressants), and elderly or carrying multiple defects.
Cholangitis with free Biliary Duct
Reflux in the digestive B.DIt seems that the isolated reflux can lead to exceptionally cholangitis. It occurs in most cases operated after bilio-digestive anastomosis, usually cholédoco ulcer.More surgical exploration or endoscopic biliary-digestive anastomoses cholédoco-duodenal found the relative frequency of food debris in stagnant CBD.Cholangitis during the infection sitting outside the CBD, this is a problem not well understood.However, in cases of suppurative cholecystitis or liver abscess in primitive or operating within the framework of a sepsis, bilicultures intraoperative, may show the presence of an infection of the bile duct with bile bile normal. The hypothesis of spasm associated oddien reaction could be considered.
hematogenously:It was suggested that the portal route involves the passage of intestinal bacteria in portal blood and bile back into the liver after treatment, but this mode of penetration of germs seems very questionable.the direct route:This mode of infection of the bile duct is now less often involved.It is the result of trauma infecting the bile ducts, mainly instrumental endoscopic maneuvers, and all surgery on the sphere hepatobiliary.Spread of infectionIs done in two ways:Local spread:Infection of the bladder directly responsible for the formation of abscesses in the walls of the bile ducts and liver parenchyma.Broadcast:Infectious process is done through blood, this blood-borne hypertension is facilitated by prevailing in VBP related to the existence of the obstacle.And several studies have demonstrated the existence of a reflux cholangioveineux bacteria on a blocked bile duct under pressure just above that of the hepatobiliary secretion.Moreover, whatever the mode of spread of infectious processes, terrain plays a supporting. Thus, cholangitis develops in a more severe in immunocompromised patients (treatment with corticosteroids and immunosuppressants), and elderly or carrying multiple defects.
Cholangitis with free Biliary Duct
Reflux in the digestive B.DIt seems that the isolated reflux can lead to exceptionally cholangitis. It occurs in most cases operated after bilio-digestive anastomosis, usually cholédoco ulcer.More surgical exploration or endoscopic biliary-digestive anastomoses cholédoco-duodenal found the relative frequency of food debris in stagnant CBD.Cholangitis during the infection sitting outside the CBD, this is a problem not well understood.However, in cases of suppurative cholecystitis or liver abscess in primitive or operating within the framework of a sepsis, bilicultures intraoperative, may show the presence of an infection of the bile duct with bile bile normal. The hypothesis of spasm associated oddien reaction could be considered.
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