2. OBJETIVOS
• Exponer la fisiopatología de la colangitis aguda y colecistitis
aguda calculosa.
• Enlistar los criterios diagnósticos de la colangitis aguda y
colecistitis aguda
• Describir los principios generales del tratamiento de la
colangitis aguda y colecistitis aguda
3. COLECISTITIS AGUDA
• Síndrome de dolor en el
cuadrante superior derecho,
fiebre y leucocitosis asociado
con inflamación de la vesícula
biliar.
• Se desarrolla en 6 a 11 % de
pacientes con cálculos biliares
sintomáticos
.MORRIS CR, HOHF RP, IVY AC. Un estudio experimental del
papel de la estasis en la etiología de la colecistitis. Cirugía
1952; 32:673.
4. FISIOPATOLOGÍA
Roslyn JJ, DenBesten L, Thompson JE Jr, Silverman BF. Papeles de la bilis litogénica y la oclusión del conducto
cístico en la patogenia de la colecistitis aguda. Am J Surg 1980; 140:126.
5. DIAGNÓSTICO
1. INFLAMACIÓN LOCAL
• Signo de Murphy
• Dolor, masa o molestia en HCD
2. INFLAMACIÓN SISTÉMICA
• Fiebre
• Leucocitosis
• PCR >3.0mg/dL
3. HALLAZGOS
RADIOLÓGICOS*
Shea JA, Berlín JA, Escarce JJ, et al. Estimaciones revisadas de la sensibilidad y especificidad de las
pruebas diagnósticas en la sospecha de enfermedad del tracto biliar. Arch Intern Med 1994; 154:2573.
7. J Hepato Biliary Pancreat, Volume: 25, Issue: 1, Pages: 55-72, First published: 16 October 2017, jDOI: (10.1002/hbp.516)
Grade I.
λ, CCI 5 or less and/or ASA class II or less (low risk);
µ, CCI 6 or greater and/or ASA class III or greater (not low risk)
ALGORITMO DE MANEJO
8. ALGORITMO DE MANEJO
J Hepato Biliary Pancreat, Volume: 25, Issue: 1, Pages: 55-72, First published: 16 October 2017, DOI: (10.1002/jhbp.516)
Grade II.
α, antibiotics and general supportive care successful;
ϕ, antibiotics and general supportive care fail to control inflammation;
λ, CCI 5 or less and/or ASA-PS class II or less (low risk);
µ, CCI 6 or greater and/or ASA-PS class III or greater (not low risk);
9. ALGORITMO DE MANEJO
Grade III.
#, negative predictive factors: jaundice (TBil ≥2), neurological dysfunction, respiratory dysfunction;
Φ, FOSF: favorable organ system failure = cardiovascular or renal organ system failure which is rapidly reversible after admission and
before early LC in AC.
in cases of Grade III, CCI (Charlson comorbidity index) 4 or greater, ASA-PS 3 or greater are high risk;
J Hepato Biliary Pancreat, Volume: 25, Issue: 1, Pages: 55-72, First published: 16 October 2017, DOI: (10.1002/jhbp.516)
10. COLANGITIS
“Es una infección de la vía
biliar, potencialmente grave.”
Jean Martin Charcot (1825—1893)
Primera descripción en 1877
"Lección sobre las enfermedades del hígado,
las vías biliares y los riñones" en la facultad de
medicina de París
A. Sokala, A. Sauvanetb, B. Fantin, V. de Lastoursa,c. 2019. Acute cholangitis:
Diagnosis and management.
11. FISIOPATOLOGÍA Y ETIOLOGÍA
1. Obstrucción de la vía biliar
Cálculos biliares (28-70%)
2. Proliferación bacteriana
a) traslocación
b) hematógena
Singh A, Mann HS, Thukral CL, Singh NR. Diagnostic accuracy ofMRCP as compared to ultrasound/CT in patients with obstruc-tive jaundice. J Clin Diagn Res
JCDR 2014;8:103—7.
Panis Y, Fagniez PL, Brisset D, Lacaine F, Levard H, Hay JM. Longterm results of choledochoduodenostomy versus choledochoje- junostomy for
choledocholithiasis. The French Association forSurgical Research. Surg Gynecol Obstet 1993;177:33—7.
14. DIAGNÓSTICO
Tokyo Guidelines (TG)
2007-2013-2018
Sensibilidad 92%
Especificidad 78%
Table 2 TG2013/2018 diagnostic criteria.
Criteria Threshold
A-Systemic
inflammation
A-1 Fever or chills > 38 ◦C
A-2 Biological Leukocytes < 4
inflammatory or > 10G/L
syndrome CRP≥10 mg/L
B-Cholestasis
B-1 Icterus/jaundice Total biliru-
bin ≥ 34 µmol/L
B-2 Abnormal liver ASAT, ALAT,
function test PAL and
gamma-
GT > 1.5 × ULN
C-Imagery
C-1 Bile duct
dilatation
C-2 Imagery
providing proof of
etiology
Suspected diagnosis One item in
A + one item in
B or C
Certain diagnosis One item in A,
B and C
CRP: C reactive protein; ASAT: aspartate aminotransferase;
ALAT: alanine aminotransferase; ULN: upper limit of normal.
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diag- nostic
criteria and severity grading of acute cholecystitis (with videos). J
Hepato-Biliary-Pancreat Sci 2018;25:41—54.
15. CRITERIOS DE GRAVEDAD
Se asocian con un aumento de la
mortalidad.
Grado 1: 1,2 %
Grado 2: 2,6 %
Grado 3: más del 5 %
Table 3 TG severity criteria 2013/2018.
Grade Criteria Threshold
Grade 3: Cardiovascular Dopamine > 5 µg/kg/
Severe dysfunction min or any dose of
At least 1 noradrenalin
criterium
Neurological Consciousness
dysfunction disorders
Respiratory PaO2/FiO2 < 300
dysfunction
Renal dysfunction Creatininuria > 176
µmol/L or oliguria
Liver dysfunction INR > 1.5
Hematological Platelets < 100,000/
dysfunction mm3
Grade 2: Leucocytes < 4 G/L or > 12G/L
Moderate
At least 2
criteria
Fever > 39 ◦C
Age > 75 years
Bilirubinemia 85 µmol/L
Hypoalbuminemia < 0.7 × ILN
Grade 1: Mild
No criteria 2
or 3
PaO2: partial pressure of oxygen; FiO2: fraction of inspired
oxygen; INR: International normalized ratio; ILN: inferior limit
of the normal.
Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and
severity grading of acute cholangitis (with videos). J Hepato-Biliary-Pancreat Sci
2018;25:17—30.
16. TRATAMIENTO
ANTIBIOTICOTERAPIA DRENAJE DE LA VÍA BILIAR
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and mana- gement of complicated intra-abdominal infection in adults and children:
guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133—64.
17. DRENAJE DE LA VÍA BILIAR
Tres modalidades:
Tratamiento quirúrgico: (hoy excepcional por su alta morbimortalidad
en comparación con el tratamiento endoscópico).
Drenaje endoscópico (CPRE o EE):
Mediante la instalación de una prótesis metálica o plástica o una
prótesis biliar, drenaje biliar
Drenaje biliar transhepático percutáneo.
Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J
Hepato-Biliary-Pancreat Sci 2018;25:31—40.
Lai ECS, Mok FPT, Tan ESY, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326:1582—6.
19. BIBLIOGRAFÍA
• Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J
Hepato-Biliary-Pancreat Sci 2018;25:17—30.
• Lai ECS, Mok FPT, Tan ESY, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326:1582—6.
• Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute
cholangitis. J Hepato-Biliary-Pancreat Sci 2018;25:31—40.
• MORRIS CR, HOHF RP, IVY AC. Un estudio experimental del papel de la estasis en la etiología de la colecistitis. Cirugía 1952; 32:673.
• Roslyn JJ, DenBesten L, Thompson JE Jr, Silverman BF. Papeles de la bilis litogénica y la oclusión del conducto cístico en la patogenia
de la colecistitis aguda. Am J Surg 1980; 140:126.
• Shea JA, Berlín JA, Escarce JJ, et al. Estimaciones revisadas de la sensibilidad y especificidad de las pruebas diagnósticas en la
sospecha de enfermedad del tracto biliar. Arch Intern Med 1994; 154:2573.
• Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and mana- gement of complicated intra-abdominal infection in adults and children:
guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133—64.
• Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis
• Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diag- nostic criteria and severity grading of acute cholecystitis (with videos). J
Hepato-Biliary-Pancreat Sci 2018;25:41—54.
Notas del editor
TG18 flowchart for the management of acute cholecystitis Grade I. λ, CCI 5 or less and/or ASA class II or less (low risk); µ, CCI 6 or greater and/or ASA class III or greater (not low risk); ▵, in case of serious operative difficulty, bail‐out procedures including conversion should be used. ASA‐PS American Society of Anesthesiologists physical status.
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