Acute Cholangitis and Pancreatitis Secondary to Common Duct Stones: Management Update

Abstract

Gallstones are found within the main bile duct (MBD) of 7% to 20% of patients undergoing cholecystectomy. MBD stones are the commonest cause of acute cholangitis and acute pancreatitis. Acute cholangitis is the result of infection superimposed on an obstructed biliary system and carries a high mortality rate if left untreated. The mainstay of treatment is a regimen of broad-spectrum intravenous antibiotics followed by prompt decompression of the obstructed biliary tree. Decompression is best accomplished by the endoscopic route, although transhepatic approaches may also be employed. Gallstone pancreatitis may be associated with cholangitis but is also common as a separate entity. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Prophylactic cholecystectomy is recommended to prevent further episodes of gallstone pancreatitis.

Current management of common bile duct stones: Is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure?

“…These centers do not perform preoperative ERCP for abnormal liver enzymes, dilated CBD, resolving gallstone pancreatitis, or other "low-yield" indications. [9][10][11][12] Similarly, our study noted that 49% of the ERCP then LC group had evidence of cholangitis, pancreatitis, or jaundice (Table III). Therefore, rather than using preoperative ERCP as the initial diagnostic tool, magnetic resonance cholangiopancreatography may accurately diagnose CBD stones without the potential complications seen with ERCP.…”

“…9 If indications for urgent duct decompression exist (cholangitis, unremitting gallstone pancreatitis), then ERCP is performed first, followed by LC before discharge. [10][11][12] A less common and more controversial approach consists of single-step LC and ERCP, in which intraoperative ERCP is performed if LC with IOC demonstrates CBD stones. [13][14][15][16] Since 1997, LC and ERCP in various sequences have been used regularly at our institution.…”

Source control in the management of severe sepsis and septic shock: An evidence-based review

“…Acute cholangitis results from obstruction of the common bile duct, most commonly as a consequence of an intraluminal stone. Bacterial proliferation occurs within the obstructed duct, and as intraductal pressures increase, bacteremia and septic shock become relatively common (49). The objective of source control interventions is relief of the obstruction and drainage of the duct through the creation of a controlled fistula, either with the gastrointestinal tract or with the skin.…”

Evaluating Patients with Right Upper Quadrant Pain

“…201,202 Between 7% and 20% of patients undergoing cholecystectomy have 1 or more stones in the common bile duct, which may be clinically silent. 203 From 20% to 30% of patients with gallstone pancreatitis have persistent common bile duct stones that fail to traverse the ampulla. 204 If a stone remains lodged in the common bile duct this can also lead to a potentially life-threatening associated ascending cholangitis.…”