Severe and Complicated Biliary Tract Disease

Tarek Abou Hamdan

Riad Azar

I. GENERAL PRINCIPLES

A. Timely diagnosis and therapy of the different biliary disorders commonly encountered in the intensive care unit (ICU) reduce the significant mortality and morbidity from unrecognized disease.

B. A practical approach to evaluate and treat biliary disorders using a wide array of noninvasive and invasive diagnostic and therapeutic aids is of paramount importance.

II. ETIOLOGY

A. Cholangitis.

1. Cholangitis occurs in patients with bile duct obstruction from stones, strictures, or recent manipulation of the biliary tree promoting bacterial translocation.

2. The clinical manifestations include fever, right upper quadrant (RUQ) abdominal pain, and jaundice (Charcot triad). In severe cases, mental status changes and hypotension can be present (Reynold pentad).

3. Laboratory abnormalities include elevated bilirubin, alkaline phosphatase, and white cell count.

4. Blood cultures are often positive for gram-negative bacteria and anaerobes.

B. Biliary obstruction without cholangitis.

1. Common causes include stone disease, benign strictures, and tumors; other causes are listed in Table 80-1.

2. When the obstruction is painless, the most likely diagnosis is a neoplasm.

C. Bile leak.

1. Bile leak can result from cholecystectomy, hepatic resection, liver transplantation, trauma, or percutaneous biliary manipulations.

2. The resultant bile peritonitis produces abdominal pain, ascites, leukocytosis, and fever.

D. Acalculous cholecystitis.

1. Acalculous cholecystitis is typically seen in critically ill patients and can result in significant morbidity and mortality.

2. High degree of suspicion is needed because symptoms may be masked by the underlying clinical situation.

TABLE 80-1 Causes of Biliary Obstruction

Intrinsic lesions
	Gallstones
	Cholangiocarcinoma
	Benign stricture
Sclerosing cholangitis
	Periarteritis nodosa
	Ampullary stenosis
	Parasites
Extrinsic lesions
	Pancreatic carcinoma
	Metastatic carcinoma
	Pancreatitis
	Pancreatic pseudocyst
	Visceral artery aneurysm
	Lymphadenopathy
	Choledochal cyst
	Hepatic cyst or cysts
	Duodenal diverticulum
	Iatrogenic lesions
	Postoperative stricture

E. Gallstone pancreatitis.

1. Evidence suggests that stone passage or impaction in the ampulla leads to pancreatitis.

2. The severity of pancreatitis can be graded based on prognostic scales that include the Ranson criteria, the Glasgow criteria, and computed tomography (CT) identifying those at risk for a complicated hospital course.

III. DIAGNOSIS

A. Physical examination.

1. Physical examination may reveal icterus, ascites, or focal RUQ tenderness.

2. Findings range from acute abdomen to fever.

B. Laboratory evaluation.

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