Surgery-cholangitis[1]

Surgery-cholangitis[1] - Cholangitis & Management of...

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Management of Choledocholithiasis Ruby Wang MS 3 Surg 300A 8/20/07
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Content Case Cholangitis Clinical manifestations Diagnosis Treatment Diagnosis and management of choledocholithiasis Pre-operative Intra-operative Post-operative
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Case HPI: 86 yo lady p/w 3-4 episodes of RUQ/mid-epigastric abdominal pain over the last year, lasting generally several hours, accompanied by occasional emesis, anorexia, and sensation of shaking chills. ROS: negative otherwise PE: VS: T 36.2, P98 , RR 18, BP 124/64 Abdominal exam significant for RUQ TTP Labs AST 553, ALT 418. Alk Phos 466. Bilirubin 2.7 WBC 30.3 Imaging Abdominal US: multiple gallstones, no pericholecystic fluid, no extrahepatic/intrahepatic/CBD dilatation
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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
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Epidemiology Nationality U.S: 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
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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. 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. 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%). Adam.about.com
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Surgery-cholangitis[1] - Cholangitis & Management of...

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