Commentary: Recurrent Pyogenic Cholangitis

Abstract

“Recurrent Pyogenic Cholangitis” (RPC) is a term that describes an advanced disease with intrahepatic stones and pus in the biliary tree. RPC occurs most frequently in Southeast Asia in patients of lower socioeconomic class who may have hepatic parasites and/or intrahepatic congenital biliary cysts. Up to two-thirds of Western patients with hepatolithiasis will present with cholangitis, and magnetic resonance imaging is recommended to establish a diagnosis. Management of cholangitis is standard with the exception that patients with recurrent episodes frequently will have resistant organisms and/or yeast. For isolated, especially left-sided, disease, lateral sectionectomy or left hepatectomy is recommended. However, the majority of patients will have bilateral disease without advanced fibrosis so liver transplantation is rarely indicated. In patients with bilateral hepatolithiasis, endoscopic management usually is not successful, but many of these patients can be treated by interventional radiologists (IR). When the stone burden is great, a combined IR and surgical (transhepatic team) approach is recommended. Intraoperative and postoperative choledochoscopy are key to this approach along with large-bore transhepatic stents which exit the liver and extend into a Roux-en-Y hepaticojejunostomy. With this “team approach” 90 % of patients remain symptom free without evidence of stone recurrence.