Managing the Patient With Abdominal Guarding and Jaundice

Issue: August 2015

ByCatherine Ngo, MD

ByJoseph Leung, MD, FRCP, FACP, FASGE, MACG

Q: A 78-Year-Old Vietnamese Woman Who Collapsed at Home Was Found to Be Febrile and in Shock with a Systolic BP of 80 mm Hg. She Is Mildly Jaundiced with Abdominal Guarding. How Would You Manage Her?

A: The emergency management of someone in shock includes initial aggressive resuscitation and identification of immediately reversible causes, including underlying cardiopulmonary events. The presence of fever, abdominal guarding, and jaundice would suggest an acute abdomen and possible biliary sepsis as a cause of the hypotension. Difficulty in the management of this elderly patient may include a language barrier, as she may not speak English, and thus the need to get help from family members or an interpreter is essential to obtain a detailed history.

Biliary sepsis complicated by shock is a serious medical/surgical condition. This is often precipitated by infection within an obstructed biliary system, which is most likely caused by biliary stones. In Western countries, most stones originate from the gallbladder. However, an Asian patient may have stones that form de novo in the bile duct (brown pigment stones) or originate from the intrahepatic ducts associated with Oriental cholangiohepatitis or recurrent pyogenic cholangitis (RPC), in which stones formed as a result of bacterial activities. These stones are more likely to give rise to biliary sepsis if ductal obstruction occurs. In general, the bacteria causing biliary sepsis are a mixture of gram negative and gram positive bacteria. Gram negative sepsis leads to endotoxemia in the presence of bile duct obstruction and accounts for the complications of suppurative cholangitis; namely, mental confusion, hypotension, renal failure, and sometimes death. Indeed, suppurative cholangitis carries a significantly higher mortality if not managed properly.

Initial management of the patient in shock in the ER includes resuscitation and stabilization while attempting to obtain a history from the patient and family. The history and clinical exam may rule out significant gastrointestinal bleeding as the cause of hypotension. An electrocardiogram (EKG) and basic blood tests should be done to evaluate for underlying cardiac conditions (including a myocardial infarction) as the cause of shock. Although the classical description of cholangitis has the triad of pain, fever, and jaundice, very often elderly patients with biliary sepsis may not develop a fever. The occurrence of mental confusion, together with shock, is a bad prognostic indicator. Blood culture should be taken to evaluate for sepsis and routine blood tests including blood count, liver function, kidney function, and coagulation profile. Initial resuscitation will include adequate IV fluid replacement. Patients with endotoxemia require a large amount of fluids to expand the circulation. However, caution should be taken to avoid overloading the patient with fluids, which may lead to heart failure. It is important to monitor the urine output with adequate fluid replacement. Avoid the use of diuretics in the beginning unless the patient has signs of fluid overload or heart failure to avoid precipitating renal dysfunction. Urgent imaging should include an abdominal ultrasound or computed tomography to evaluate for gallstone disease, any evidence of dilated common bile duct or intrahepatic ducts, or the presence of bile duct stones causing obstruction.

After obtaining a blood culture, the patient should be given broad-spectrum antibiotics to guard against possible gram negative and gram positive infections. The most common organisms causing biliary sepsis include Escherichia coli, Klebsiella, Enterococcus, and possible anaerobic bacteria. In general, we recommend giving a second- or third-generation cephalosporin or a fluoroquinolone (eg, ciprofloxacin). In very sick patients, we add metronidazole to cover against possible anaerobic infection. Ampicillin or augmentin IV is given if blood culture isolates gram positive bacteria. Caution should be taken when considering an extended use of ciprofloxacin to avoid long-term complications.

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Patients with acute cholangitis will usually respond to conservative treatment with fluid replacement and antibiotics therapy. In patients with complete bile duct obstruction associated with stone impaction, the intrabiliary pressure is elevated, which prevents the effective excretion of antibiotics into bile to control the infection. Suppurative cholangitis occurs in 20% of patients with complete obstruction. These patients may fail to respond to conservative management and will require urgent biliary decompression. Clinical signs and symptoms that warrant urgent drainage include high fever, persistent shock with dropping blood pressure and increasing tachycardia, and persistence of abdominal pain and tenderness, indicating a raised intrabiliary pressure.

Urgent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic drainage is the best approach to the management of patients with suppurative cholangitis because of the lower morbidity and mortality when compared with emergency surgery or percutaneous transhepatic drainage. Because of an associated bleeding tendency from obstructive jaundice and possible disseminated intravascular coagulation with platelet dysfunction from sepsis, we recommend biliary decompression using a stent or nasobiliary drain, often without a papillotomy if successful deep common bile duct (CBD) cannulation can be achieved.

Elderly patients with sepsis do not tolerate IV sedation well and it is important to avoid oversedation. It may be necessary to request anesthesiology support for sedation in critically ill patients undergoing an emergency biliary drainage procedure. It is important to understand that cholangitis is a result of stasis and infection, and the goal of urgent ERCP is to provide drainage of the obstructed biliary system and not necessarily complete clearance of the bile duct.

**Figure 1.** Ten-Fr stent and large CBD stone in dilated bile duct.

**Figure 2.** Ten-Fr stent draining pus from obstructed biliary system. Infected bile aspirated from obstructed biliary system (inset).

**Figure 3.** (A) Impacted stone at the ampulla. (B) Polypectomy snare applied around the impacted stone and bulging papilla. (C) Impacted stone removed with snare. (D) Drainage of dark bile after stone disimpaction.

During emergency ERCP for patients with underlying bile duct stones, selective bile duct cannulation may be easy because of the patulous papilla as a result of previous stone passage. Minimal contrast should be injected into the bile duct to define the level of obstruction and detect any ductal stones. It is important to avoid a full cholangiogram or overfilling of the intrahepatic ducts because this will increase the intrabiliary pressure and precipitate or worsen the sepsis. Urgent decompression should be performed if the diagnostic catheter or papillotome can be inserted beyond the level of the obstruction with the help of a guidewire. Active suction of the infected bile using a 20-mL syringe connected to the catheter or papillotome should be performed (especially in very ill patients) to decompress the biliary system. Subsequent exchange of the catheter can be performed over an indwelling guidewire for either a nasobiliary catheter or a biliary stent to provide biliary drainage. We prefer to use a 10-Fr straight stent (eg, Cotton Leung stent [Cook Endoscopy]) because it provides better drainage than the smaller 7- or 8.5-Fr stent, especially when the bile is infected (Figure 1). The straight stent is also better than double pigtail stents because of the larger proximal side holes. In general, an 8-cm 10-Fr stent will suffice for biliary drainage in case of CBD stone obstruction (Figure 2). Bile should be taken for culture to isolate the bacteria causing the infection and to monitor the antibiotic sensitivity.

An impacted stone may sometimes be seen at the papilla, causing a bulging papilla and obstruction. The impacted stone may prevent deep cannulation with either the catheter or papillotome. In cases where the stone is seen emerging from the papilla, we have successfully removed the impacted stone using a polypectomy snare by ensnaring the bulging papilla beyond the impacted/obstructing stone. The snare is closed beyond the stone and gentle tugging of the snare will dislodge the stone from the papilla (Figure 3). Subsequent cholangiogram should be performed, and we recommend placement of a biliary stent to insure drainage.

In some cases, the impacted ampullary stone prevents successful or deep CBD cannulation. In such cases, it may be necessary to perform a needle knife precut papillotomy. The impacted stone causes stretching of the papilla and distal CBD and protects the pancreatic orifice. The stone serves as a “chopping board” and allows the precut papillotomy to be performed safely. The precut papillotomy can be completed using a standard papillotome when deep cannulation is successful. Alternatively, the precut papillotomy can be further extended using the needle knife until the impacted stone dislodges spontaneously. In most cases, deep cannulation is successful and the papillotomy can be extended and completed using a standard papillotome. We recommend insertion of an indwelling biliary stent to insure adequate decompression of the biliary system to prevent cholangitis.

With successful biliary drainage, biliary infection will respond to antibiotic therapy. The clinical condition of the patient often improves with hemodynamic stability and resolution of the fever. We recommend completing a full course of antibiotics for at least 1 week, or for 3 to 5 days after the fever has subsided. A repeat ERCP is performed 2 to 4 weeks after the patient improves clinically to remove the biliary stent, and subsequent papillotomy is performed (if necessary) to remove any residual CBD stone.

Subsequent management after complete CBD clearance of stones will depend on the general condition of the patient and the presence or absence of stones in the gallbladder. We may recommend a subsequent elective cholecystectomy if the gallbladder contains stones. In high-risk patients or those without gallstones, the gallbladder can be left alone if complete clearance of the biliary system is achieved.

Excerpted from:

References:
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Leung JW, et al. Lancet. 1989;i(8650):13071309.
Leung JW, Cotton PB. Am J Gastroenterol. 1990;86(4):389394.
Leung JW, et al. Gastrointest Endosc. 1994;40(6):716721.
Pan YL, et al. J Interv Gastroenterol. 2011;1(4):177-178.

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