Ch. 54 – Biliary System

A
Recurrent Pyogenic Cholangitis
Cholangiohepatitis or intrahepatic stones are endemic in
East Asia. It is uncommon in North America except in
the Chinese population. It is more common in people
with poor economic status and living standards. The
infectious aspect of this disease is caused by bacterial
contamination, usually biliary pathogens, and biliary parasites,
such as Clonorchis sinensis, Opisthorchis viverrini,
and Ascaris lumbricoides. Biliary sludge and dead bacterial
cell bodies form brown pigment stones formed
throughout the biliary tree, which cause partial obstruction.
Biliary strictures and repeated episodes of cholangitis
are the common clinical course and may lead to
hepatic abscesses and cirrhosis. Patients are at risk for
cholangiocarcinoma due to persistent biliary infection
and irritation from stones and sludge.
Presentation
Patients with recurrent pyogenic cholangitis (RPC) commonly
present with frequent episodes of pain, fever, and
jaundice. MRC and PTC are the primary imaging modalities
for monitoring of disease progression (Fig. 54-25).
They are useful for identifying location and severity of
Chapter 54 Biliary System 1573
Figure 54-24 A posteroanterior radiograph obtained during a barium examination of the small bowel shows an
irregular collection of barium in the right upper quadrant (A, arrowheads), representing partial fi lling of the cystic
duct. Both jejunum and ileum are markedly dilated, with dilution of the barium in a pattern consistent with small
bowel obstruction. There is abrupt termination of the barium column at the site of an oval intraluminal fi lling
defect (A, arrow). A view of the end of the barium column shows luminal obstruction by a smooth intraluminal
mass (B, arrows) with faint calcifi cation of the peripheral rim. Exploratory laparotomy revealed a foreign body in
the terminal ileum that was 4 cm by 4 cm and felt hard. (From Kaiser AM, Molmenti EP: Gallstone ileus. N Engl
J Med 335:942, 1996.)
B
stones and strictures and allow decompression of the
biliary tree in a septic patient.
Management
Patients with RPC should be treated with a multidisciplinary
approach including endoscopists, interventional
radiologists, and surgeons because of the frequency and
inaccessibility of strictures and stones. The long-term goal
of therapy is to extract stones, remove debris, and relieve
strictures. Because clearance of all stones at any one
operation is diffi cult, Roux-en-Y hepaticojejunostomy
with a subcutaneous afferent limb (Hudson loop) is a
safe and effective way to provide access to the biliary
tree for stone extractions. 36 Cholangiocarcinoma has been
reported in 1% to 10% of patients with RPC; therefore,
patients with adequate hepatic reserve and a dominant
lobe with stones should undergo extended hepatectomy
of the involved side, Roux-en-Y hepaticojejunostomy,
and Hudson loop. This would remove the stones and
reduce the future risk for cholangiocarcinoma. About 50%
of patients require further percutaneous choledochoscopy
or balloon dilation to clear any remaining stones or
manage persistent strictures.