Seminar

1. Case Presentation
Presented by: Dr. Collins Saa Bowah (Mmed surgery)
Dr. Chiloleti Geofrey (Mmed Urology)
Supervised by: Dr. Mwanga
June 20th , 2022

2. Introduction
Name: M. K. L
Age: 76 years old
Marital status: Married
Residency: Morogoro rural
Informant: Son

3. • Known patient who was diagnosed to have obstructive jaundice
sec to cholangiocarcinoma 2months ago
• 2 weeks post PTBD (External biliary drainage)

4. Chief complains
i-Fluid leakage per incision site 1/52
ii-Fever 5/7
iii- Abdominal pain 5/7

5. History of presenting illness
• The patient was apparent well until one week ago when he started
observing fluid leakage per incision site.
• The leakage was yellowish-greenish , which later on was with mixed
with puss , the fluid leakage was not associated with foul smelling, it
was not itching
• Has a history of surgical treatment 2 weeks ago due to his illness as
part of continue treatment
• No history of trauma to the surgical site

6. History of presenting illness
• Abdominal pain, upper part of abdomen, Gradual onset
• Colicky in nature, progressive
• Abdominal pain was associated with vomiting for 2 days prior to
admission, non projectile, non bilious, mixed with recent food
particles
• Episode of the vomitus was between 2 to 3 per day

7. History of presenting illness
• Furthermore , he experience low grade fever which started on gradual
onset, on and off no specific periodicity
• More markedly during the night
• Fever was relieved with taking paracetamol

8. History of presenting illness
One month ago Prior to this admission
The patient presented with
- Right upper quadrant pain 6/12
- Yellowish discoloration of eye 6/12

9. History of presenting illness
• Right upper quadrant pain 6/12
-Of gradual onset progressive as time goes dull in nature , Non radiating
-Not associated with fever, no vomiting, no nausea
-No history of difficulty in swallowing and regurgitation
-No history of early satiety and abdominal fullness

10. History of presenting illness
-No history of blood in stool , Passing mucoid stool
-No history of altered bowel habits
-No history of similar condition in the family

11. History of presenting illness
• Yellowish discoloration of the eye 6/12
-Started on gradual onset, increase in severity
-was progressive , not intermittent, not fluctuating
-No aggravating no relieving factor

12. History of presenting illness
-Associated with passage of deep yellow urine
-Associated with generalized body itching, and clay stool colored
-No history of bleeding tendency

13. History of presenting illness
-No history of deworming habit in his life
-There history of living in areas with livestock keeping in his lifetime
-There is significant unintentional weight loss
-There is history of Alcoholism consumption local beer, for past 40yrs
-There is history of cigarrete smoking 10pack-per day

14. History of presenting illness
-No history of blood transfusion before the onset to illness,
-No history of multiple sexual partners and practicing unprotected sexual
intercourse,
-No history of tattooing
-No history of drug abuse
-Has habitual consumer of groundnuts and mushrooms

15. Course of the illness
• During the course of the illness, the patient visited the MNH on may
and an impression of obstructive jaundice secondary to tumor of the
head of the pancreas.
• He took oral herbs in an attempt to remedy the problem prior to visit
here at MNH.
• He was later sent to do a CT Scan outside where he did the scan at
Mloganzila hospital.

16. Course of the illness
• He was managed with a drain into the gall bladder, and discharge
home for a revisit after one month. Patient revisited as a known patient
with obstructive jaundice two weeks later with pain and discharges
from the biliary catheter site .
• He came with fluid leakage per abdominal wound two weeks with
yellowish-green discharge.

17. Course of the illness
After several workouts and investigations, the patient was then admitted
and reevaluated.

18. ROS
• Has history of productive cough with whitish sputum for over 10years now.
• No history of chest pain nor TB
• No history of Diabetes
• No history of awareness of heart beat nor difficulty in lying flat.
• No history of LOC , no history of convulsion.

19. PMH
• No history of previous hospital admission
• No history of other chronic illnesses such as CVA, HTN or DM.
• No history of allergies to food or medications.

20. Family and Social history
• He is married with seven children
• Not insure
• No familial illness he could remember

21. General Examination
• Elderly man, Alert, and in no apparent respiratory distress but painful
distress.
• severely malnourished, listless and is able to sit up in bed unsupported.
• No palpable peripheral , supraclavicular, axillary nor inguinal lymph
nodes.
• No oral thrush and neck mass
• Bilateral grade II pitting edema

22. General Examination
• Afebrile to touch, non-pallor, No
• Has a percutaneous drain insitu, no finger clubbing
• Temp: 38.6 Celsius
• BP: 82/60 mmHg
• PR: 80 beats/min
• SPO2: 98%
• RR: 18 cycles/min
• RBG: 15g/dl

23. SHEENT
• Black and grey hair with normal distribution
• Skin generally jaundiced
• Sclera icteric, conjunctiva pale, pupils reflex to light
• No ear discharge, nor nose discharge

24. Abdominal Examination
• Scaphoid abdomen, inverted umbilicus and symmetrical
• Moves with respiration
• Drain in RUQ insitu
• Right upper quadrant tenderness, murphy’s sign positive

25. Abdominal Examination
• Palpable liver and spleen
• Tympanic percussion note except for anatomic dullness
• Normoactive bowels sound
• DRE: Normal anal verge, intact sphincter tone, Prostate grade ii, firm,
free rectal mucosa, with palpable semi-solid stool in rectal vault, glove
finger stained with fecal material.

26. Respiratory System Examination
• Normal chest contour, symmetrical and moves with respiration
• Good air entry bilaterally
• Normal bilateral tactile vocal fremitus
• Trachea is centrally located

27. Cardiovascular System Exam
• Warm extremities, cap refill <2 secs
• Pulse : See above BP: See above
• No distended neck veins
• PMI at 5th ICS -MCL

28. Neurological Examination
• GCS: 15/15
• Intact cranial nerves
• Muscle power and Normal muscle tone
• Intact sensory sensation, normal reflexes

29. Summary
• M.K.L, a 76years old male patient presented with the chief complaint of Fluid leakage per
incision site, fever and Upper abdominal pain
• Patient previous diagnosed with Obstructive jaundice sec to cholangiocarcinoma
+Yellowish discoloration, Body itching, RUQ pain, clay stool
+ Alcohol consumption
+ Cigarrete smoking ( 10 pack per day)
+ Fever
P/E
+Hypotension
+Murmphy sign
+Palpable gallbladder
+Hypotension

30. Diagnosis
• Provisional dx:
• 1
• 2
• Differential dx:
• 1
• 2
• 3

31. Diagnosis
• Provisional diagnosis:
• Ascending Cholangitis sec Post PTBD
• Cholangiocarcinoma
• Gallbladder tumor
• Differential Dx:
• Acute cholecystitis
• Liver abscess
• Acute hepatitis

32. Full Blood Picture and Electrolytes
Investigation May 25, 2022 June 12, 2022 References
WBC 8.66 12.84 4-10
ABS Neutrophils 4.962 11.39 2-6.9
Neutrophils 57.19 88.70 40-80
Lymphocytes(Abs) 2.736 1.212 .6-3.4
Lymphocytes 31.53 9.434 20-40
ABS Monocytes .0336 .1566 0-0.9
Monocytes .3871 Low 1.220 2-10
ABS Eosinophils 0.937 High .0751 0-0.7
Eosinophils 10.80 High .5848 1-6
ABS Basophils .0076 .0078 0-2
Basophils .0880 Low .0605 .02-0.1
RBC 4.277 Low 4.714 4.5-5.5
HBG 11.23 Low 12.44 13-17
HCT 37.91 Low 39.74 40-50

33. Investigation for FULL BLOOD PICTURE
and Serum Electrolytes
Investigation May 25, 2022 June 12, 2022 References
MCV 88.64 84.29 83 - 99
MCH 26.25 Low 26.39 27-32
MCHC 29.62 Low 31.31 31.5 – 34.5
RDW 16.14 Low 15.87 11.6 – 14.8
Platelets 214.7 170.2 150 - 410
potassium 3.7 3.0 3.5 – 5.1
Sodium 135 135 136 - 145
Chloride 103 102 98 - 107

34. Investigation for Renal and Liver Functions
Investigation May 25, 2022 June 12, 2022 References
Urea Nitrogen 24,1 3.2 – 7.4
Creatinine 150.2 108.2 63.6 –m110.5
ALT(SGPT) 26 26 0 – 55
AST (SGOT) 59 42 5 - 34
C-Reactive Protein 138.1 0 - 5
Direct Bilirubin 165.6 144.7 0 – 8.6
Total Bilirubin 290.3 199.5 3.4 – 20.5

35. Radiology investigation
• Abdominal ultrasound
• CT Scan
• Please see CT Scan on this case.

36. Report for CT Scan
• Incremental scans were obtained from the diaphragm to the pelvic
brim after oral contrast before and after intravenous contrast
• An enlarged liver about 15.6cm with centrally located necrotic lesion
in the right lobe at segment IV measuring 2.8cm X 2.9 cm X 2.1cm.
• A mass seen at the porta hepatis occupying the common hepatic duct
at the confluence of the right and left intrahepatic ducts , measuring
5.5 x 5.6 x 3.4cm. It is associated with markedly dilated intrahepatic
ducts. Has mass effect on the adjacent bowel loop and appears to make
the gall bladder difficult to be seen.

37. • Normal pancreas
• Enlarged spleen
• All pelvic organs were normal

38. Final Diagnosis
• Ascending Cholangitis sec PTBD
• gall bladder tumor
• Cholangiocarcinoma
• Portal hypertension secondary to portal hepatis tumor

39. Management ongoing
• Metronidazole 500mg T.D.S 5/7
• IV ceftriaxone 1g OD 5/7
• Inj. Vit. K 10mg O.D
• Zinc oxide
• N.G tube feeding
• TPBD revision`
• NS, DNS
• IR review
• Paracetamol 1g O.D 3/7

40. Current status of the patient (Drain Insitu)
Note that the patient’s consent was obtained for this purpose

41. Literature review
Cholangitis

42. Introduction
Cholangitis is bacterial infection superimposed on biliary obstruction
First described by Jean-Martin Charcot in 1850s as a serious and life-
threatening illness
• Causes
• Choledocholithiasis
• Obstructive tumors
• Pancreatic cancer
• Cholangiocarcinoma
• Ampullary cancer
• Porta hepatis
• Others
• Strictures/stenosis
• ERCP
• Sclerosing cholangitis
• AIDS
• Ascaris lumbricoides

43. EPIDEMIOLOGY
US: uncommon, and occurs in association with biliary obstruction and causes of
bactibilia (s/p ERCP)
Internationally:
• Oriental cholangiohepatitis
endemic in SE Asia- recurrent
pyogenic cholangitis with
intrahepatic/extrahepatic stones
in 70-80%
• Gallstones highest in N
European descent, Hispanic
populations, Native Americans
• Intestinal parasites common
in Asia
• Sex
• Gallstones more common in
women
• M: F ratio equal in cholangitis
• Age
• Median age between 50-60
• Elderly patients more likely to
progress from asymptomatic
gallstones to cholangitis without
colic

44. Epidemiology
• In Tanzania, Infectious disease 2014 edition,
• The case-fatality rate is 7% to 40%, and is highest in patients
with hypotension, renal failure, liver abscess, cirrhosis,
inflammatory bowel disease, malignant strictures and advanced
age, or delays in diagnosis or surgery

45. Pathogenesis
• Normally, bile is sterile due to
constant flush, bacteriostatic bile salts,
secretory IgA, and biliary mucous;
Sphincter of Oddi forms effective
barrier to duodenal reflux and
ascending infection
• ERCP or biliary stent insertion can
disrupt the Sphincter of Oddi barrier
mechanism, causing pathogeneic
bacteria to enter the sterile biliary
system.

46. Pathogenesis
Obstruction from stone or tumor
increases intrabiliary pressure
• High pressure diminishes host
antibacterial defense- IgA production,
bile flow- causing immune
dysfunction, increasing small bowel
bacterial colonization.

47. Pathogenesis
• Bacteria gain access to biliary tree by
retrograde ascent
• Biliary obstruction (stone or stricture)
causes bactibilia
• E Coli (25-50%)
• Klebsiella (15-20%),
• Enterobacter (5-10%)
• High pressure pushes infection into biliary
canaliculi, hepatic vein, and perihepatic
lymphatics, favoring migration into
systemic circulation- bacteremia (20-
40%).

48. Clinical Manifestations
• RUQ pain (65%)
• Fever (90%)
• May be absent in elderly patients
• Jaundice (60%)
• Hypotension (30%)
• Altered mental status (10%)
Charcot Triad
Found in 50-
70% of
patients
Reynold’
Pentad

49. Additional History
• Pruritus, acholic stools
• PMH for gallstones, CBD stones,
• Recent ERCP, cholangiogram
Additional Physical
• Tachycardia
• Mild hepatomegaly

50. Diagnosis: Lab values
• CBC
• 79% of patients have WBC > 10,000, with mean of 13,600
• Septic patients may be neutropenic
• Metabolic panel
• Low calcium if pancreatitis
• 88-100% have hyperbilirubinemia
• 78% have increased alkaline phosphatase
• AST and ALT are mildly elevated
• Aminotransferase can reach 1000U/L- micro abscess formation in the liver
• GGT most sensitive marker of choledocholithiasis
• Amylase/Lipase
• Involvement of lower CBD may cause 3-4x elevated amylase
• Blood cultures
• 20-30% of blood cultures are positive

51. Image: Ultrasonography
• Advantage:
• Sensitive for
intrahepatic/extrahepatic/CB
D dilatation
• CBD diameter > 6 mm
on US associated with
high prevalence of
choledocholithaisis
• has a sensitivity of 79-
98%
• Rapid at bedside
• Can image aorta, pancreas,
liver
• Identify complications:
perforation, empyema,
abscess

52. Image: Ultrasonography
• Disadvantage
• Despite its high sensitivity Not useful for the distal CBD may not always
be visible on US due to bowel gas and structures.
• 10-20% falsely negative
• normal U/S does not r/o cholangitis
• acute obstruction when there is no time to dilate
• Small stones in bile duct in 10-20% of cases

53. Image: CT scan
• Advantages
• CT cholangiography enhances CBD
stones and increases detection of
biliary pathology
• Sensitivity for CBD stones is
95%
• Can image other pathologies:
ampullary tumors, pericholecystic
fluid, liver abscess
• Can visualize other pathologies-
cholangitis: diverticulitis,
pyelonephritis, mesenteric ischemia,
ruptured appendix
• Disadvantages
• Sensitivity to contrast
• Poor imaging of gallstones

54. Diagnostic: MRCP
Magnetic resonance
cholangiopancreatography
(MRCP)
• Advantage
• Detects choledocholithiasis,
neoplasms, strictures, biliary
dilations
• Sensitivity of 81-100%,
specificity of 92-100% of
choledocholithiasis
• Minimally invasive- avoid
invasive procedure in 50% of
patients

55. • Disadvantage:
• cannot sample bile, test cytology, remove stone
• Contraindications: pacemaker, implants, prosthetic valves
• Indications
• If cholangitis not severe, and risk of ERCP high, MRCP useful
• If Charcot’s triad present, therapeutic ERCP with drainage should
not be delayed.

56. Diagnostic: ERCP
Endoscopic retrograde
cholangiopancreatography (ERCP)
• Gold standard for diagnosis of CBD
stones, pancreatitis, tumors, sphincter of
Oddi dysfunction
• Advantage
• Therapeutic option when CBD stone
identified
• Stone retrieval and sphincterotomy
• Disadvantage
• Complications: pancreatitis,
cholangitis, perforation of duodenum
or bile duct, bleeding
• Diagnostic ERCP complication rate
1.38% , mortality rate 0.21%

57. Tokyo Guideline 2018
Classification of Ascending cholangitis
• The Tokyo Guidelines 2018 (TG18) are a revision of the 2013 guidelines (TG13),
and incorporate new evidence based on validation studies of TG13.
• Kiriyama et al (2017) studied 6,063 patients who were clinically diagnosed
with acute cholangitis, and found that the TG13 guidelines diagnosed 90% of
these patients retrospectively with acute cholangitis. 30-day mortality rates of
patients with Grade III, Grade II, and Grade I were 5.1%, 2.6%, and 1.2%,
respectively, and increased significantly along with disease severity.
• Objectively guides diagnosis and management of patients with acute cholangitis in
terms of timing and need for biliary drainage and supportive care.
• Charcot’s triad (fever, right upper quadrant pain, jaundice) has high specificity but
low sensitivity for acute cholangitis (Kiriyama et al 2017)

58. Patient must have a suspected diagnosis (≥1 item in A + ≥1 item in B or C) or
definite diagnosis (≥1 item in A, B, and C) to meet entry criteria for severity
grading, see table below:
Criteria
Part A
Systemic
inflammation
Fever (>38°C/100.4°F) and/or shaking chills
Laboratory data: evidence of inflammatory response (WBC <4 or >10 x1,000/μL
and/or CRP ≥1 mg/dL)
Part B
Cholestasis
Jaundice (total bilirubin ≥2 mg/dL)
Laboratory data: abnormal liver enzymes (ALP, γGTP, AST, ALT levels >1.5 x STD)
Part C
Imaging
Biliary dilatation
Evidence of the etiology on imaging (stricture, stone, stent, etc.)

59. Severity grading system
Grade III (dysfunction in ≥1 of the following):
Cardiovascular dysfunction: hypotension requiring dopamine ≥5 μg/kg per min or any dose of norepinephrine
Neurological dysfunction: disturbance of consciousness
Respiratory dysfunction: PaO₂/FiO₂ ratio <300
Renal dysfunction: oliguria or creatinine >2.0 mg/dL
Hepatic dysfunction: PT‐INR >1.5
Hematological dysfunction: platelet count <100,000/mm³
Grade II (≥2 of the following conditions):
Abnormal WBC count (>12,000/mm³ or <4,000/mm³)
High fever (≥39°C/102.2°F)
Age ≥75 years
Hyperbilirubinemia (total bilirubin ≥5 mg/dL)
Hypoalbuminemia (<0.7 x upper limit of normal)
Grade I
Does not meet the criteria of Grade III or Grade II acute cholangitis at initial diagnosis

60. Grade
Acute cholangitis
severity
Recommendations
I Mild
Antibiotics and general supportive care; consider
biliary drainage if no response to initial treatment
II Moderate
Antibiotics and general supportive care; early
endoscopic or percutaneous transhepatic biliary
drainage is indicated
III Severe
Initial treatment with antibiotics, urgent biliary
drainage, appropriate respiratory/circulatory
management

61. MANAGEMENT
• Upon diagnosis of acute cholangitis (regardless of severity) initial treatment generally consists
of antibiotics, fluid resuscitation, electrolyte repletion, and appropriate analgesic administration.
• Grade I (mild):
• In most cases, initial treatment as above is sufficient, and most patients do not require
biliary drainage.
• However, biliary drainage should be considered if a patient does not respond to initial
treatment within 24 hrs.
• Grade II (moderate):
• Early (within 48 hrs of admission) endoscopic or percutaneous transhepatic biliary drainage
is indicated.
• Grade III (severe):
• Treat underlying sepsis aggressively with respiratory (tracheal intubation) and circulatory
(pressors) support.
• Emergent (as soon as patient is hemodynamically stable) endoscopic or percutaneous
transhepatic biliary drainage is indicated.

62. Medical Treatment
• Resuscitate, Monitor, Stabilize if patient unstable
• Consider cholangitis in all patients with sepsis
• Antibiotics
• Empiric broad-spectrum Abx after blood cultures drawn
• Ampicillin (2g/4h IV) plus gentamicin (4-6mg/kg IV daily)
• Carbapenems: gram negative, enterococcus, anaerobes
• Levofloxacin (250-500mgIV qD) for impaired renal fxn.

63. - 80% of patients can be managed conservatively 12-24 hrs Abx
- If fail medical therapy, mortality rate 100% without surgical
decompression: ERCP or open
- Indication: persistent pain, hypotension, fever, mental confusion

64. Surgical treatment
• Endoscopic biliary drainage
• Endoscopic sphincterotomy
with stone extraction and
stent insertion
• CBD stones removed in
90-95% of cases
• Therapeutic mortality
4.7% and morbidity 10%,
lower than surgical
decompression

65. • Surgery
• Emergency surgery replaced by non-operative biliary drainage
• Once acute cholangitis controlled, surgical exploration of CBD for difficult
stone removal
• Elective surgery: low M & M compared with emergency survey
• If emergent surgery, choledochotomy carries lower M&M compared with
cholecystectomy with CBD exploration

69. Referrence
1. Boey JH, Way LW. Acute cholangitis. Ann Surg 1980;191:264-70
2. Csendes A, Diaz JC, Burdiles P, et al. Risk factors and classification of acute suppurative cholangitis. Br J Surg 1992;79:655-8
3. Thompson JE Jr, Tompkins RK, Longmire WP Jr. Factors in management of acute cholangitis. Ann Surg 1982;195:137-45
4. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326:1582-6
5. Wani S, Sultan S, Qumseya B, et al. The ASGE’S vision for developing clinical practice guidelines: the path forward.
Gastrointest Endosc 2018;87:932-3
6. Iqbal U, Khara HS, Hu Y, et al. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis.
Gastrointest Endosc 2020;91:753-60
7. Bramer WM, Giustini D, de Jonge GB, et al. De-duplication of database search results for systematic reviews in EndNote. J
Med Libr Assoc 2016;104:240-3
8. Kumar R, Kwek A, Tan M. Outcomes of intensive care unit (ICU) patients with cholangitis requiring percutaneous transhepatic
biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) [abstract]. Gastrointest Endosc
2016;83:AB247-8
9. Park CS, Jeong HS, Kim KB, et al. Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very
elderly patients. Hepatobil Pancreat Dis Int 2016;15:619-25

71. • As for the diagnostic accuracy of diagnostic imaging for malignant
tumors, there is a report showing that the sensitivity/specificity/rate of
correct diagnosis of US for extrahepatic bile duct cancers are
85.6/76.9/84.4 % for cancers of the hilar bile duct; 59.1/50/57.1 % for
cancers of the middle bile duct; and 33.3/42.8/36.8 % for cancers of
the lower bile duct, respectively [16]. There are reports showing that
about 100 % of the tumors of the biliary system, except early cancers,
are recognized with multi-detector CT and a judgment of the
usefulness of resection can be made in 74.5–91.7 % of the cases
[17, 18]. A meta-analysis of MRCP has found that its sensitivity and
specificity are 97/88 and 98/95 %, respectively, when the detection of
obstruction/malignancy has been set as the end point [19].