Monika Bibyan, Radha Govind Khandelwal, Prasanna Kumar Reddy
Department of Surgical Gastroenterology and Minimal Access Surgery,
Apollo Hospital, Chennai - 600006, Tamil Nadu, India
Corresponding Author:
Dr. Prasanna Kumar Reddy
Email: drpkreddy@hotmail.com
48uep6bbphidvals|545 48uep6bbph|2000F98CTab_Articles|Fulltext Oriental cholangiohepatitis is endemic in the Asia-Pacific region. We are presenting two cases of oriental cholangiohepatitis managed by hepatic resection.
Case reports
Case 1
A 40-year-old woman presented with recurrent pain abdomen and fever with chills since last 2 years. There was no history of jaundice. The haemogram showed a haemoglobin of 10.3 gm%, leucocyte count of 10,290/cumm, and an ESR of 50 mm/hr. Liver function tests showed bilirubin 0.3 mg/dl, ALP 221 IU/L, SGPT 13 IU/L, and GGTP 27 IU. USG abdomen showed left lobe atrophy with dilatation of intrahepatic radicals with intraductal calculi seen in proximal segment of the left hepatic duct. The common bile duct was mildly dilated. CT findings were suggestive of oriental cholangiohepatitis with stricture of the left hepatic duct with dilatation of intrahepatic biliary radicals, intraductal calculi and atrophy of the left lobe of liver (Figure 1). Cholecystectomy and left hepatectomy were performed for the condition. The post-operative period remained uneventful. The intra-operative bile culture showed growth of E. coli. Histopathology findings were consistent with chronic cholangiohepatitis and subacute
cholecystitis.
Case 2
A 45-year-old woman presented with generalised weakness and low grade intermittent fever since two years. Her liver function tests were normal.USG abdomen showed left liver lobe atrophy. MRCP showed intrahepatic calculi, left hepatic duct stricture and left lobe atrophy (Figure 2). Left hepatectomy and cholecystectomy was done, and the patient made an uneventful recovery.
Discussion
Oriental cholangiohepatitis (OCH) with intrahepatic stones is commonly seen in Asia, particularly in China, Hong Kong, Korea and Japan. The principles of hepatolithiasis management include clearance of stones, correction of strictures, removal of lesions and restoration of biliary drainage.[1] Most patients present with acute cholangitis which is managed by intravenous fluids, antibiotics and analgesics. Urgent biliary decompression is requisite to prevent the patient from going into shock.
Decompression can be achieved by endoscopic, radiologic or operative approaches. Endoscopy may be a successful treatment option for migrating stones in the absence of bile duct strictures. Interventional radiology by percutaneous approach may help treat intrahepatic lithiasis secondary to the stricture of bilioenteric anastomoses. Intracorporeal or extracorporeal shock-wave lithotripsy can be useful when combined with endoscopic or percutaneous procedures.[2]
Surgical options include cholecystectomy, exploration of the common duct and choledochoscopy with or without hepaticojejunostomy, hepatico-cutaneous jejunostomy, and partial hepatectomy. Hepatic resection can reduce the risk of recurrence of stones, since it removes not only intrahepatic stones but also the associated pathological bile ducts damaged by strictures.[3] Indications for hepatectomy include, (i) unilobar hepatolithiasis, particularly involving the left sided; (ii) atrophy, fibrosis and multiple cholangitic abscesses; (iii) suspicion of concomitant cholangiocarcinoma; (iv) multiple intrahepatic stones with biliary strictures that cannot be treated percutaneously or endoscopically. Non-surgical therapy is most useful in bipolar hepatolithiasis without strictures or in patients who pose high surgical risk or have short life expectancies.[4] If the liver parenchyma is diffusely affected by the disease, cirrhosis, and portal hypertension, liver transplantation may be the only alternative.
In conclusion, liver resection remains the definitive surgical option for OCH as it removes the stones as well as the strictures and the possibility of carcinoma.
References
- Ling XF,Xu Z,Wang LX, Hou CS,Xiu DR,Zhang TL,Zhou XS. Long-term outcomes of choledochoduodenostomy for hepatolithiasis. Chin Med J. 2010;123:137–41.
- Nuzzo G, Clemente G, Giovannini I, De Rose AM, Vellone M, Sarno G, et al. Liver resection for primary intrahepatic stones: a single-center experience. Arch Surg. 2008;143:570–3; discussion 574.
- Uenishi T, Hamba H, Takemura S, Oba K, Ogawa M, Yamamoto T, et al. Outcomes of hepatic resection for hepatolithiasis. Am J Surg. 2009;198:199–202.
- Sakpal SV, Babel N, Chamberlain RS. Surgical management of hepatolithiasis. Oxford: HBP; 2009 .p.194–202.
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