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Postoperative choledocholithotomy through the fistula formed by T-tube placement in the common bile duct fungus like protist examples ketoconazole 200 mg buy low cost. Management of bilateral hepatolithiasis is more complicated than the management of unilateral hapatolithiasis. Indeed, Chen and colleagues (1997) reported the rate of complete stone clearance was 84% at 1 year after operation, despite 60% of the patients having remnant stones immediately after the operation. In addition, combining hepatectomy and hepaticojejunostomy with anchoring of the jejunal A. A, A case of secondary hepatolithiasis after excision of congenital choledochal cysts. Some filling defects (arrows) in the left hepatic duct were demonstrated on magnetic resonance cholangiopancreatography. B, Three-dimensional computed tomography shows marked atrophy of the left hemiliver with diminished portal flow. D, Resected specimen shows marked atrophy and impacted stones in the left hemiliver. If stones recur several years after complete stone clearance, this jejunal limb can be used as an access route to the biliary system under local anesthesia. Some consider this a useful procedure for prevention of bacterial reflux into the liver (Herman et al, 2005). However, complementary hepaticojejunostomy itself may cause cholangitis (Kusano et al, 2001). Herman and colleagues (2010) confirmed that all patients submitting to liver resection only showed good results, whereas 7 of 17 patients (41. In an attempt to clarify the drawback of bilioenteric anastomosis, they compared only patients with unilateral disease, with and without hepaticojejunostomy; there was a significant difference between the groups, showing the negative effects of the bilioenteric anastomosis on patient outcome. Bilateral partial resection of the liver may provide good longterm results even in the patients with bilateral intrahepatic stones and stenosis (Yang et al, 2010). The incidence of stone recurrence after bilateral and unilateral hepatectomy for bilateral intrahepatic stones was 11. However, it should be noted that there were three hospital deaths among 54 patients in the bilateral resection group, which were related to postoperative liver failure. Even in patients with bilateral stones, stone recurrence rates are low and comparable to that of unilateral stones if the extent of liver resection is equal to stone-affected segments (Li et al, 2012). The safety of hepatectomy has improved, but the postoperative complication rates, including wound infection, hemobilia, and biliary fistula, are still 15.

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Frozen-section analysis of any grossly abnormal tissue can be considered fungus gnats eating seeds discount 200 mg ketoconazole fast delivery, but it is often appropriate to proceed with a cancer operation if gross findings are suspicious for malignancy (see Chapter 49). It has been speculated that in such situations, there is no stimulus for gallbladder contraction, the bile becomes inspissated, and biliary sludge forms. The exact pathogenesis is unknown but likely involves some combination of ischemia, biliary stasis, and sepsis (Hakala et al, 1997; Warren, 1992), and inspissated bile and sludge seem to play some causative role. Although this condition traditionally has been described in the patient groups mentioned earlier, several reports suggest an increase in the de novo presentation of acalculous cholecystitis in the outpatient population, including patients with atherosclerotic vascular disease, such as seen in hypertension and diabetes (Parithivel et al, 1999; Ryu et al, 2003; Savoca et al, 1990). Overall, acalculous cholecystitis represents approximately 5% to 15% of all cases of acute cholecystitis. A male predominance is seen in cases of acalculous cholecystitis, in contrast to acute calculous cholecystitis, which occurs more commonly in women (Kalliafas et al, 1998; Ryu et al, 2003; Wang et al, 2003). In addition, three factors were correlated with an increased risk for acalculous cholecystitis in this high-risk population: (1) high injury-severity score, (2) increased heart rate, and (3) transfusion requirement at the time of admission. This study suggests that more acutely injured patients, who are expected to require prolonged ventilatory and nutritional support, are at higher risk for acalculous cholecystitis (Pelinka et al, 2003). Clinical Manifestations Part of the difficulty in making the diagnosis of acalculous cholecystitis is that many patients seen with this condition are critically ill and require ventilatory support and sedation. Gallstones and Gallbladder Chapter 33 Cholecystitis 561 the signs and symptoms of acute calculous cholecystitis (Ryu et al, 2003). The most frequent physical and laboratory findings are fever, right upper quadrant pain, leukocytosis, and hyperbilirubinemia. These findings are often nonspecific, however, in the setting of sepsis and critical illness (Kalliafas et al, 1998). The incidence of gangrene and perforation seems to be increased in patients with acalculous cholecystitis compared with acute calculous cholecystitis, likely because of the delay in diagnosis that is common with this disease. Severe gallbladder complications such as gangrene, perforation, and empyema occur more commonly in older patients with an elevated white blood cell count (Ryu et al, 2003; Wang et al, 2003). In many series, the risk of severe gallbladder complications was found to be 50% to 60% (Kalliafas et al, 1998; Swayne, 1986; Wang et al, 2003). This high risk may be the result of the disturbance in capillary microcirculation that has been shown in pathologic studies on gallbladder specimens after cholecystectomy for acalculous cholecystitis (Hakala et al, 1997; Warren, 1992). Diagnostic Evaluation and Imaging Imaging algorithms for patients with suspected acalculous cholecystitis are similar to algorithms for patients with acute cholecystitis. The difficulty with interpreting these findings is that many critically ill, parenteral nutrition­dependent patients have these findings.

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Unilobar atrophy is associated with hypertrophy of the contralateral lobe and may present diagnostic and operative difficulties fungus we eat ketoconazole 200 mg order with visa. Liver lobe atrophy and Pathologic Consequences Fibrosis Biliary obstruction is associated with the formation of high local concentrations of bile salts at the canalicular membrane, and these initiate pathologic changes in the liver (Schaffner et al, B. Biliary Stricture and Fistula Chapter 42 Biliary fistulae and strictures 701 compensatory hypertrophy are frequently found in benign strictures and may be associated with asymmetric involvement of lobar or sectoral hepatic ducts, interference with portal venous blood supply, or decreased portal perfusion owing to secondary fibrosis. In benign strictures, the dilated ducts within the atrophic segments often are filled with infected bile and debris, and even though drainage of an atrophic segment would not be effective in relieving jaundice, cholangitis may continue unabated unless satisfactory drainage of the atrophic and hypertrophic segments is achieved. The presence of significant atrophy and compensatory hypertrophy greatly influences the approach to repair (see Chapter 31). The most common situation is gross hypertrophy of the left lobe accompanied by right lobe atrophy (Czerniak et al, 1986). Anastomosis in the region of the hilum is made difficult by the rotational deformity and anatomic distortion imposed by this condition. A thoracoabdominal approach to such strictures may be necessary to provide more direct exposure and access for repair by allowing rotation of the liver to the left (Bismuth & Lazorthes, 1981). Recent reports verify that the presence of atrophy and contralateral hypertrophy are associated with significantly longer reconstructive operations, higher intraoperative blood loss, and greater blood transfusion requirements (Pottakkat et al, 2009). Radiologic Investigations Duplex ultrasonography is an excellent, noninvasive means of showing intrahepatic ductal dilation and may reveal a subhepatic fluid collection or evidence of vascular damage (see Chapter 15). In patients with biliary strictures, complete delineation of the level and extent of injury is necessary. All branches of the right and left intrahepatic biliary tree must be outlined, particularly in cases of high bile duct stricture and recurrent stricture after previous reconstruction. Displaying the hepatic duct confluence (if intact) and the left ductal system and its branches is especially important in selecting the appropriate reconstruction. Multiple Portal Hypertension It is estimated that approximately 15% to 20% of patients with benign biliary stricture have concomitant portal hypertension (Blumgart & Kelley, 1984; Chapman et al, 1995) (see Chapter 76). Patients with biliary strictures may develop portal hypertension as a result of secondary hepatic fibrosis or direct damage to the portal vein. It is important that these patients undergo further workup to exclude underlying chronic parenchymal disease. Iatrogenic biliary injuries are often the subject of medicolegal proceedings, and precise documentation of all injuries is essential to provide an accurate assessment of the cause of symptoms and prognosis. The outcome of patients with biliary strictures and portal hypertension is much worse than for patients without portal hypertension, with an in-hospital mortality rate of 25% to 40% (Blumgart & Kelley, 1984; Chapman et al, 1995). It has been suggested, however, that adequate biliary drainage may be followed by some resolution of fibrosis and perhaps a reduction in portal pressure (Blumgart, 1978).

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The management of cholangitis should follow three principles: (1) vigorous resuscitation and hemodynamic support fungus guard cheap ketoconazole 200 mg visa, (2) broad-spectrum parenteral antibiotics, and (3) relief of biliary obstruction (decompression). However, it cannot be overstated that the definitive treatment for cholangitis is biliary decompression. Culture-identified bacteriology of the biliary tree has changed over the past 40 years. Previously, the gram-negative aerobes Escherichia coli and Klebsiella, gram-positive aerobes, and enterococci were the most common C. Biliary Infection and Infestation Chapter 43 Cholangitis 715 isolates identified from patients with cholangitis (Helton, 1987). More recently, infections have been polymicrobial in 30% to 80% of cases (Westphal & Brogard, 1999). In some studies, anaerobes have been detected in more than 15% of patients but rarely as the sole isolate. Bacteroides and Clostridium species are the most frequently cultured anaerobes, and anaerobic bacteria are commonly isolated from biliary tract specimens from patients who have a history of biliary surgery, especially those with a biliary-enteric anastomosis or chronic biliary tract infection and the elderly. Cholangitis arising from anaerobic organisms is reported to be associated with a more severe clinical illness compared with purely aerobic infections (Csendes et al, 1996) (see Chapter 12). The organisms isolated reflect a similar distribution to that of biliary cultures, except for anaerobes and enterococci, which are infrequently found in blood cultures. A variety of antibiotic regimens and combinations have been compared in prospective randomized clinical trials to establish efficacy, safety, and toxicity profiles. Monotherapy with broad-spectrum agents, such as a third- and fourthgeneration cephalosporins (cefotaxime, cefipime), and a ureidopenicillin (mezlocillin, piperacillin) combined with a -lactamase inhibitor (ticarcillin-clavulanate, piperacillin-tazobactam) or quinolone (ciprofloxacin) have been reported to be as effective in treating patients with cholangitis as metronidazole or clindamycin in combination with an aminoglycoside or a thirdgeneration cephalosporin and ampicillin (Sung et al, 1995; Thompson et al, 1993). In a multicenter comparative study of cefepime versus broad-spectrum antibacterial therapy in moderate and severe bacterial infections (Badaro et al, 2002), cefepime was demonstrated to achieve a higher cure rate compared with broadspectrum combination therapy as an initial empiric treatment for hospitalized patients with moderate to severe communityacquired infections. Carbapenems, ureidopenicillins, and fluoroquinolones offer good coverage for gram-negative aerobes (Mazuski et al, 2002), but piperacillin offers the advantage of gram-positive coverage, including enterococci, as well as anaerobic coverage (Thompson et al, 1990). Tazobactam, a -lactamase inhibitor, extends the spectrum to cover organisms that have acquired resistance. These regimens are sufficient for most patients presenting with de novo cholangitis who have not yet been hospitalized, operated upon, or instrumented (Table 43. Again, it is emphasized that although hydration and antibiotics may improve the clinical condition in up to 80% of patients with acute cholangitis, 20% with clinical sepsis will require urgent biliary decompression. Control infection and relieve obstruction Biliary lithiasis Nonlithiatic obstruction 11. Primary sclerosing cholangitis: antibiotics and restabilishing biliary drainage 14. Liver transplant patients who develop cholangitis have been observed to have Candida and/or Enterococcus in the biliary tree. Interestingly, vancomycin-resistant enterococci are common in liver transplant patients (Schlitt et al, 1999). When Candida and/or Enterococcus are cultured, these should be treated with amphotericin and one of the streptogramins (quinupristin/ dalfopristin [Synercid] or oxazolidinone linezolid [Zyvox], respectively).

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Mason, 24 years: Goldman L, et al: Multifactorial index of cardiac risk in noncardiac surgical procedures, N Engl J Med 297:845­850, 1977. It is the archetypal proinflammatory cytokine associated with antitumor immune responses. The most common reason for major bile duct injury is failure to identify the anatomy of the triangle of Calot (Strasberg et al, 1995). Results and conclusions from numerous series comparing early and late surgical therapy in gallstone pancreatitis are difficult to interpret.

Gamal, 54 years: Zhong L, et al: Magnetic resonance cholangiopancreatography, Chin J Dig Dis 5:139­148, 2004. Jorgensen T: Abdominal symptoms and gallstone disease-an epidemiological investigation, Hepatology 9(6):856­860, 1989. The incidence of distal choledochoduodenal fistula secondary to cholelithiasis or operative trauma is variable in different parts of the world. Muraji T, et al: Surgical management for intractable cholangitis in biliary atresia, J Pediatr Surg 37:1713­1715, 2002.

Aldo, 61 years: When this occurs, gallstones are diagnosed by the "wall echo shadow" sign produced by echoes from the anterior gallbladder wall, echogenic anterior surface of the stone, and posterior acoustic shadowing produced by the stone. For example, hilar cholangiocarcinoma rarely gives rise to peritoneal disease; however, it is often unresectable due to local tumor extension and/or vascular involvement, which is difficult to determine laparoscopically. After this was recognized, increased efforts in awareness, education, and training have decreased the risk. Bile salts are a chemical barrier to infection and have several important properties (see Chapter 8).

Chenor, 21 years: The research community has incredible resources at its disposal, ranging from patient databases to complex sequencing equipment. Malignant strictures tend to be longer (18 to 22 mm) and have a thicker wall (2 mm) than benign strictures, and they show arterial- or portal-phase bile duct hyperenhancement (Choi et al, 2005). Hoglund M, et al: Computed tomography with intravenous cholangiography contrast: a method of visualizing choledochal cysts, Eur J Radiol 10:159­161, 1990. Lalezari D, et al: Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks, World J Gastrointest Endosc 5(7):332­339, 2013.