Primary or recurrent pyogenic cholangitis

This differs from ''secondary cholangitis' in that: (1) It has no known cause; it is not secondary to stones, strictures, carcinoma, or worms. (2) The primary pathology is not in the gall-bladder, but in the bile-ducts (intra- or extrahepatic), which contain sludge and pigment stones. (3) Treatment involves drainage of the bile-ducts, not removal of the gall-bladder, unless it is very distended and gangrenous. (5) Symptoms commonly recur (unusual in secondary cholangitis). This was one of the most common abdominal emergencies in East Asia[md]China, Korea, Taiwan, Hong Kong and Malaysia, but its incidence is now declining.

The patient, who is usually between 30 and 40 years (the sexes are affected equally) presents with a high swinging fever, chills, and rigors, a gnawing right upper abdominal pain, and mild jaundice (Charcot's triad), usually with a history of previous attacks. His liver is tender and enlarged and his gall- bladder may be palpable. His urine is dark, but his stools are seldom clay-coloured[md]complete obstruction of the common bile- duct is rare.

PRIMARY PYOGENIC CHOLANGITIS SPECIAL TESTS. The patient's white count is raised, so is his serum bilirubin (3 mg/dl or more). If infection is severe and his liver cells are involved, his transaminases are raised. Measure his serum amylase, because there is a 10% chance that he also has pancreatitis.

X-RAYS. A plain X-ray may show air in his biliary tract due to an incompetent sphincter of Oddi.

During an acute attack neither an oral nor an intravenous cholangiogram will demonstrate his biliary system. Four weeks later an intravenous cholangiogram may show filling defects in his common bile-duct.

NON-OPERATIVE TREATMENT. If the disease is mild, take blood cultures and give him antibiotics (cephradine or gentamicin, 2.9). Give him 10 mg of vitamin K[,1]. Give him intravenous fluids, and aspirate his stomach through a nasogastric tube.

INDICATIONS FOR OPERATION. (1) the failure of non- operative treatment. (2) A palpable, tender, enlarged gall- bladder. (3) Septicaemia. (4) Peritonitis.

LAPAROTOMY. Aim to remove all biliary grit and mud by washing out his extra- and intrahepatic bile-ducts with copious amounts of saline. If this is impossible, do a wide ([mt]2.5 cm) choledochoduodenostomy so that stones that are left behind can pass into his gut without totally obstructing his biliary tree.

If he is very ill with septicaemia or peritonitis, do a cholecystostomy if his gall-bladder is enlarged. If it is shrunken and his common duct dilated, do a choledochostomy, and insert a T-tube. Refer him for a choledochoenterostomy or cholecystectomy 6 weeks later.

If you cannot refer him and you are sufficiently skilled, do a choledochoduodenostomy, or a choledochojejunostomy (13.8) at that time.