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Wei-Zhong
Zhang, Yi-Shao Chen, Jin-Wei Wang, Xue-Rong Chen, Department of
Surgery, Huangyan First Hospital, Huangyan 318020, Zhejiang
Province, China
Correspondence to: Dr. Wei-Zhong Zhang, Department of Surgery，Huangyan
First Hospital, Huangyan 318020, Zhejiang Province, China. pgmh @
mail.tzptt.zj.cn
Telephone:+86-576-4016922
Received 2001-07-05 Accepted 2001-11-15
Abstract
AIM:
To
investigate the diagnostic standard for early identification of
severe acute cholangitis in order to lower the incidence of
morbidity and mortality rate.
METHODS:
A diagnostic standard was proposed in this study as follows:
documented biliary duct obstruction by ultrasound or computerized
tomography or other imaging tools with the manifestation of systemic
inflammatory response syndrome (SIRS). The surgical procedures
included emergency common bile duct exploration with T tube
insertion or cholecystostomy with secondary common bile duct
exploration. And incidence of postoperative multiple organ
dysfunction syndrome (MODS), duration of systemic inflammatory
response and hospital mortality were analyzed.
RESULTS:
Fourty-three patients conforming to the diagnostic standard
described above were employed in this study. 1 patient was admitted
in acutely ill condition and complicated with acute relapse of
chronic bronchitis, cholecystostomy procedure was performed but the
patient was complicated with postoperative acute lung injury which
was treated by assisted mechanical ventilation for 5 d; 2 wk later,
two-stage common bile duct Exploration and T tube insertion were
performed. The remaining 42 patients underwent primary common bile
duct exploration and T tube insertion, 1 developed acute lung injury
and recovered 3 d later, 2 patients developed acute renal
dysfunction, 1 of which recovered 2 d later and the other died on d
4. For all patients, the postoperative systemic inflammatory
response persisted for 2 to 8 d with median of 3 d.
CONCLUSION:
Early diagnosis of severe acute cholangitis can be made using this
diagnostic standard, further development of systemic inflammatory
response could be prevented and incidence of MODS as well as
hospital mortality decreased.
Zhang
WZ, Chen YS, Wang JW, Chen XR. Early diagnosis and treatment of
severe acute cholangitis.
World J Gastroenterol 2002;8(1):150-152
INTRODUCTION
Severe
acute cholangitis takes a severe clinical course, systemic
inflammatory response syndrome (SIRS) appears at early stage and
followed by multiple organ dysfunction syndrome (MODS), which
signifies poor prognosis[1-8]. Recently, the
perioperative management and technique of anesthesia have been much
improved, however, the mortality and morbidity of the patients with
severe acute cholangitis remain high, especially in local hospitals.
This study was performed to investigate the standard for early
diagnosis of severe acute cholangitis and its surgical timing in
order to decrease the complications.
MATERIALS
AND METHODS
Diagnostic
criteria
In this study, we proposed the diagnostic criterion for severe acute
cholangitis as follows: documented obstruction of biliary duct by
ultrasound, CT or other radiological imaging[9-19] if the
patient presents two or more of the following conditions: ①temperature
more than 38℃
or less than 36℃,
②elevated
heart rate more than 90·min-1, ③respiratory
rate more than 20·min-1 or PaCO2 less than
4.27KPa, and ④white
blood cell count more than 12×109·L-1, less
than 4×109·L-1, or immature granulocyte more
than 0.10[20]
Clinical
materials
Between January 1997 and November 2000, 43 consecutive patients
conforming to proposed diagnostic criterion for severe acute
cholangitis were admitted in surgical department of our hospital, of
which 26 were male and 17 were female, the average age was 53±8
years and the average APACHE II score was 9.2±2.6. 27 patients had
stones only in common bile duct; the remaining 16 had both
intrahepatic and extrahepatic stones
After
admission, proper preoperative preparation was carried out and all
patients underwent emergency biliary duct decompression, including
common bile duct exploration with T tube drainage or cholecystostomy
with secondary choledochostomy.
After
operation, patients were intensively monitored on multiple organ
systems. Hospital mortality was taken as death during
hospitalization for the severe cholangitic attack, and death
attributed to the underlying biliary sepsis in the absence of other
obvious contributory cause within 48 h after emergency biliary duct
drainage.When postoperative serum creatinine doubled or exceeded 180μmol·L-1
among patients who had a normal preoperative value or when it
increased 100μmol·L-1 over its deranged
preoperative level, the diagnosis was renal dysfunction. Respiratory
dysfunction was taken as the necessity for mechanical ventilation at
any time after admission because of acute cholangitis. And duration
of systemic inflammatory response was measured.
RESULTS
One
patient aged 65 years was admitted in critically ill condition with
APACHE II score of 15 and was complicated with acute relapse of
chronic bronchitis, therefore, cholecystostomy procedure was
performed but he was complicated with postoperative acute lung
injury which was treated by assisted mechanical ventilation for 5 d;
2 wk later, common bile duct was explored and T tube inserted. After
20 d, he was discharged. The remaining 42 patients underwent
first-stage common bile duct exploration and T tube placement,
however, 1 developed acute lung injury and was managed by mechanical
ventilation for 3 d; 2 patients developed acute renal dysfunction,
one of which recovered 2 d later and the other died on d4. For all
patients, the postoperative systemic inflammatory response persisted
for 2 to 8 d with median of 3 d.
DISCUSSION
Acute
cholangitis caused by obstruction of common bile duct can easily
induce systemic inflammatory response and later MODS or MOF, the
clinical mortality is high. In China, a symposium on hepatic and
biliary duct stones was held by Chinese Association of Surgery at
Chongqing city in 1983, and the diagnostic standards for severe
acute cholangitis was recommended. The diagnosis was met when
patient presents shock or two of following six parameters: nervous
symptoms; pulse more than 120·min-1; white blood cell
counts more than 20×109·L-1 ; temperature
more than 39℃
or less than 35℃;
biliary duct filled with pus and highly pressured; positive blood
culture. In western country, diagnosis of severe acute cholangitis
was established when septic shock or mental obtundation was
confirmed in patients with acute cholangitis[21].
However, many patients with severe acute cholangitis were not
manifested with nervous dysfunction and hypotension; the incidence
of Reynolds' pentad was low; recent study showed that culture is far
less sensitive than PCR method in detecting microbes present in
blood[22-23]; and with progress in technique of modern
imaging, obstruction of biliary duct can be identified early and
accurately and proper management can be achieved timely; last but
not least, patients with the diagnosis of severe acute cholangitis
by this standard usually presented severe systemic inflammatory
response, suggestive of the presence of multiple organ dysfunction,
so if the patients were operated on at this time, second hit would
ensue and course leading to MOF was accelerated[24],
mortality increased accordingly. At that time, when diagnosis was
established, biliary drainage was of immediate concern, the surgical
procedures included common bile duct exploration and T tube
insertion, or cholecystostomy when patient's condition was unstable,
but mortality rate carried between 10 per cent and 40 per cent.[1-3,
25]
In
the era of minimally-invasive surgery, when the diagnosis of severe
acute cholangitis is confirmed, the principle of management has much
changed[26-32]. Non-operative biliary decompression is
attempted before any definitive surgical procedure is undertaken. A
nasobiliary catheter by endoscopy can be left in place to provide
short-term biliary decompression until the patient's cholangitis
resolves. The goal of such treatment is to convert an urgent or
emergent problem into one that can be managed in an elective
setting.Emergent surgical decompression of the common bile duct is
reserved for patients in whom endoscopic procedure is either
unsuccessful or unavailable. Should a surgical procedure be
necessary, the goal is to establish biliary decompression only by
means of a choledochotomy, and placement of a large diameter T-tube.
Overall, non-operative drainage can be accomplished with morbidity
rates of less than 40 per cent and overall mortality of less than 10
per cent.
Lai
et al in early 1990s conducted a randomized prospective study
on the role of endoscopic biliary drainage for severe acute
cholangitis, the diagnosis of severe acute cholangitis was based on
the presence of either septicemic shock or evidence of progressive
biliary sepsis including mental confusion and persistent or
relapsing fever despite appropriate antibiotic treatment, however,
the mortality rate remained up to 10 percent. Recently, they
conducted a retrospective study to evaluate the combined endoscopic
and laparoscopic approach in managing gallstone cholangitis, in
their series, 60 patients had severe acute cholangitis defined by
the presence of septic shock, mental confusion, or persistent high
fever despite antibiotic treatment and the mortality rate among
patients with severe acute cholangitis decreased to 5.0 per cent
(3/60) [21]. They concluded that combined approach is
safe and effective for managing gallstone cholangitis. Other authors
had reported similar advantages of nonoperative decompression[27-30].
The
advent of endoscopic retrograde cholangiopancreatography, endoscopic
sphincterotomy and newer laparoscopic procedures including common
bile duct exploration has remarkably decreased the mortality of
severe acute cholangitis[33-37]. However, the performance
of these procedures is dependent on training, technical skills and
experience of the surgeon. In the hands of an experienced surgeon, a
laparoscopic approach is reasonable for the treatment of acute
cholangitis in the tertiary hospitals[33]. But in the
primary or local hospitals which don't have the experienced
endoscopic surgeon or equipment, the management of patients with
severe acute cholangitis has to be turned to traditional procedures.
Furthermore, a recent multicenter randomized trial comparing
surgical treatment with endoscopic management in patients with
common bile duct stones showed that surgical treatment was
associated with lower major complications like MODS (4 % vs 13%) and
less retained stones (6% vs 16%) than endoscopic management[38].
And other complications of nonoperative management were also noted.[39-40]
As
we know, in the situation of severe acute cholangitis, the
intraductal pressure rises secondary to obstruction, bacteria and
endotoxins can leak into the systemic circulation and induce
systemic inflammatory response[4-7] and a frequent
complication of this inflammatory response is the development of
organ system dysfunction or failure[20, 41-42].
Therefore, the management of severe acute cholangitis should be
based on the early awareness of the disease by clinicians, the
objective of this study was to establish the early diagnosis of
severe acute cholangitis.
An
American College of Chest Physicians/Society of Critical Care
Medicine Consensus Conference (ACCP/SCCM) was held in August 1991 to
produce a series of universal definitions for SIRS (systemic
inflammatory response syndrome), sepsis and other clinical
conditions related to sepsis, the aim of the consensus conference
was to improve our ability to make early detection of the disease
possible, and thus allow early therapeutic intervention to decrease
morbidity and mortality[20, 42]. Based on this
background, we recommended a new diagnostic standard since January
1997, that was, SIRS manifestation with documented obstruction of
biliary duct by imaging, and surgical procedure for decompression
mainly was common bile duct exploration and T tube drainage. 43
consecutive patients conforming to proposed diagnostic criterion for
severe acute cholangitis were employed in this study. 1 patient aged
65 years was admitted in acutely ill condition and complicated with
acute relapse of chronic bronchitis, cholecystostomy procedure was
performed but he was complicated with postoperative acute lung
injury which was treated by assisted mechanical ventilation for 5 d;
2 wk later, two-stage common bile duct Exploration and T tube
insertion were performed. The remaining 42 patients underwent
primary common bile duct exploration and T tube insertion, however,
1 developed acute lung injury and recovered later; 2 patients
developed acute renal dysfunction, one of which recovered 2 d later
and the other died on d4. Therefore, all patients in this cohort
were diagnosed and managed timely, preventing SIRS from further
progressing, thus the incidence of MOD was low (9.3%, 4/43) and
mortality rate decreased (2.3%, 1/43).
In
conclusion, the preliminary results of this prospective study showed
that if the systemic inflammatory response is identified early in
the disease process of severe acute cholangitis, MODS can be
effectively prevented and mortality decreased, the proposed
definition for severe acute cholangitis is practical and should be
clinically accepted. Furthermore, a randomized controlled
prospective study should be done to confirm this conclusion.
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