• Nama : Nurhayat Usman, dr.

, SpB-
KBD., FINACS
• No. Telp : +62 811227330
• E-mail : nurhay16@yahoo.com

• 1983 S1 Dokter Umum FK UNPAD

• 1992 Sp.1 / Dokter Spesialis Bedah FK UNPAD
• 1996 Sp.2 / Dokter Bedah Digestif FK UNPAD

• Kepala Divisi Bedah Digestif Departemen Ilmu

Bedah FK. UNPAD / RSUP Dr. Hasan Sadikin
Bandung

1
Nurhayat Usman, dr. Sp.B-KBD. FInaCS
 Definisi & Terminologi

• Definisi : kondisi inflamasi akut dan infeksi di saluran

empedu
• Terminologi :
– 1877 : “demam hati”  Charcot, kemudian
dikenal sebagai Trias Charcot : demam intermiten
+ menggigil, nyeri perut kanan atas, ikterus
– 1959 : Reynolds & Dargan  sindrom :
penurunan kesadaran dan syok, demam, ikterus,
dan nyeri perut yang disebabkan oleh obstruksi
bilier  Pentas Reynolds  dekompresi bilier
 Epidemiology
• Nationality
– U.S: uncommon, and occurs in association with biliary obstruction and causes of
bactibilia (s/p ERCP)
– Internationally:
• Oriental cholangiohepatitis endemic in SE Asia- recurrent pyogenic cholangitis
with intrahepatic/extrahepatic stones in 70-80%
• Gallstones highest in N European descent, Hispanic populations, Native
Americans
• Intestinal parasites common in Asia

 Sex
 Gallstones more common in
women
 M: F ratio equal in
cholangitis
 Age
 Median age between 50-60
 Elderly patients more likely
to progress from
asymptomatic gallstones to
cholangitis without colic
• Wang,R, Cholangitis and Management Choledocholithiasis, 2007
• Sharma G et all ,Acute Cholangitis in Current Surgery Therapy,2014
 ANATOMI :
Duktus Biliaris Ekstrahepatal

• Terdiri dari : duktus hepatik kiri dan

kanan, duktus hepatik komunis (CHD),
duktus sistikus (CD), duktus biliaris
komunis (CBD).
• CHD :
– Panjang 1-4 cm, diameter ± 4 mm
• CD :
– Panjang bervariasi
– Anatomisnya memiliki berbagai variasi
– Segment CD yang berhubungan dengan
GB memiliki lipatan mukosa berbentuk
spiral : valvula Heister.
• CBD :
– Panjang 7-11 cm. diameter 0.5-1 cm
– masuk ke duodenum pars II melalui
sfingter Oddi
 Vaskularisasi
• Suplai dari arteri sistikus
– 95 % merupakan cabang dari
arteri hepatika dextra
kemudian bercabang 2 anterior
dan posterior.
• Jarang : cabang : a.
gastroduodenal
– Lokasi : segitiga Calot
Aliran darah balik : sebagian
besar melalui vena – vena
kecil yang langsung menuju
ke liver
– hanya sebagian kecil yang
menuju vena sistikus yang
besar dan kemudian menuju ke
vena porta.
 FISIOLOGI

• Hepar memproduksi empedu secara kontinyu dan mengeksresikan

ke dalam duktus biliaris

• Produksi empedu : 500 - 1000 mL/hari

• Sekresi empedu dipengaruhi oleh stimuli saraf, hormon, dan kimia.

– Stimulasi vagal meningkatkan sekresi empedu
– Stimulasi nervus splanchnic menurunkan aliran empedu
– Asam klorida, protein, asam lemak di dalam duodenum
menstimuli sekresi sekretin dari duodenum  meningkatkan
produksi dan aliran empedu.
 FISIOLOGI

Efek cholecystokinin pada kandung empedu dan sfinkter Oddi. A. Dalam kondisi puasa,
sfinkter Oddi kontraksi dan kandung empedu diisi. B. Ketika ada makanan, respon
sfinkter Oddi relaksasi dan kandung empedu kontraksi (pengosongan)
 Fungsi Kandung empedu

• Kandung empedu, duktus biliaris dan sfingter oddi

secara bersama – sama berfungsi untuk menyimpan
dan mengatur aliran dari empedu.

• Fungsi utama dari kandung empedu untuk

memekatkan dan menyimpan empedu dari liver 
duodenum [respon terhadap makanan]
Patofisiologi Pembentukan Batu Empedu
• Kolesterol dan lemak-lemak
lain : tidak larut dalam air
• Struktur “micelle” 
agregasi garam empedu dan
lesitin yang bersifat
amfoterik dengan inti di
dalamnya adalah kolesterol,
 membuat kolesterol
dapat larut dalam air.
• Kemampuan maksimal
micelle untuk mengangkut
kolesterol disebut the critical
micellar concentration
Patofisiologi Pembentukan Batu Empedu

• Patofisiologi terbaru???
• Diagram trikoordinat untuk
menentukan indeks
saturasi kolesterol.
• Area yang diarsir : cairan
misellar yang larut dalam
air
• Faktor2 lain : stasis, infeksi
bakteri, tingkat absorpsi air
dan elektrolit, terapi
estrogen, dan kehamilan
 Kolangitis Akut
• Klasifikasi Longmire :
– Pasien dng 3 karakteristik : demam intermiten
+ menggigil, nyeri perut kanan atas, ikterus 
kolangitis supurativa akut
– Pasien dng letargi dan syok + 3 hal diatas :
kolangitis supurativa obstruktif akut.
– 5 bentuk kolangitis akut:
1. Kolangitis akut yang berkembang dari kolesistitis akut
2. Kolangitis akut non-supuratif
3. Kolangitis akut supuratif
4. Kolangitis akut supuratif obstruktif
5. Kolangitis akut supuratif disertai dengan abses hati.
 Etiologi
• Etiologi :
– Diperlukan kehadiran 2 faktor :
1. Obstruksi bilier
2. Pertumbuhan bakteri dalam empedu
(infeksi)
– Penyebab tersering : koledokolitiasis,
stenosis bilier, striktur, keganasan,
instrumentasi
Sharma G et all ,Acute Cholangitis in Current Surgery Therapy,2014
 Clinical Manifestations
• RUQ pain (65%) Reynold’s
Charcot’s
• Fever (90%) Triad: Pentad:
Found in
– May be absent in elderly patients
50-70%
• Jaundice (60%) of
patients
• Hypotension (30%)
• Altered mental status (10%)
Additional History
Pruitus, acholic stools
PMH for gallstones, CBD stones,
Recent ERCP, cholangiogram
Additional Physical
Tachycardia
Mild hepatomegaly
• Wang,R, Cholangitis and Management Choledocholithiasis, 2007
• Sharma G et all ,Acute Cholangitis in Current Surgery Therapy,2014
Kriteria Diagnostik

Tokyo Guidelines 2018

Derajat Keparahan
 Diagnosis: lab values
• CBC
– 79% of patients have WBC > 10,000, with mean of 13,600
– Septic patients may be neutropenic
• Metabolic panel
– Low calcium if pancreatitis
– 88-100% have hyperbilirubinemia
– 78% have increased alkaline phosphatase
– AST and ALT are mildly elevated
• Aminotransferase can reach 1000U/L- microabscess formation in the liver
– GGT most sensitive marker of choledocholithiasis
• Amylase/Lipase
– Involvement of lower CBD may cause 3-4x elevated amylase
• Blood cultures
– 20-30% of blood cultures are positive

Wang,R, Cholangitis and Management Choledocholithiasis, 2007

 Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
– Advantage
• Detects choledocholithiasis, neoplasms, strictures, biliary dilations
• Sensitivity of 81-100%, specificity of 92-100% of choledocholithiasis
• Minimally invasive avoid invasive procedure in 50% of patients
– Disadvantage:
• Cannot sample bile, test cytology, remove stone
• Contraindications: pacemaker, implants, prosthetic valves
– Indications
• If cholangitis not severe, and risk of ERCP high, MRCP useful
• If Charcot’s triad present, therapeutic ERCP with drainage should not be
delayed.

Endoscopic retrograde cholangiopancreatography (ERCP)

– Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi
dysfunction, effective in establishing billiary drainage 90-88 %
– Advantage
• Therapeutic option when CBD stone identified
• Stone retrieval and sphincterotomy
– Disadvantage
• Complications: pancreatitis, cholangitis, perforation of duodenum or bile
duct, bleeding
• Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

Wang,R, Cholangitis and Management Choledocholithiasis, 2007

Flow chart
Flow chart
 Teknik Drainase Bilier
Endoskopi vs Perkutaneous vs Surgikal ??

Surgikal : pada kasus-kasus neoplasma irresectable tanpa

ada batu  drainase eksterna dengan insersi T-tube
 Laparoscopic CBD Exploration
• In 1989, laparoscopic removal of gallbladder replaced open surgery
– In the past decade, laparoscopic CBD exploration (LCBDE) developed
• Techniques
– IOC define biliary anatomy: size and length of cystic duct, size of bile duct stones
– Choledochotomy
• If cystic duct < CBD stone, If CBD > 6mm
• If stone located proximal to cystic duct-common bile duct junction
• If stone impacted in bile duct or papilla
– Transcystic approach
• If CBD < 6mm in diameter
• Cystic duct dissected close to junction with CBD, transverse incision made
• Guidewire into CBD through cholangiogram catheter under fluoroscopy
• Isotonic NaCl irrigate CBD to flush small stones through sphincter of Oddi
• Unsuccessful in 10-20% of patients
• Contraindications : pancreatitis, sphincter anomalies,
• Results
– High rate of lap CBD clearance: 73-100%
• Similar success rates between transcystic and choledochotomy
– Conversion to open 5.2-19.6%
• Causes : multiple/impacted stones, bleeding, unclear anatomy,equipment failure
– Length of hospital stay shorter in LCBDE than ES
– Mortality and Morbidity
• No difference between LCBDE and ES

Cochrane database of systematic reviews 2007

Single-and two-stage management for cholecysto-choledocholithiasis
had similar mortality and complication rates; however, the single-
stage strategy was better in terms of stone clearance, hospital stay
and total operative time.
Recommended treatment algorithm based
on calculated mortality risk
 Kesimpulan
• Diagnosis, Severity Acute Cholangitis,
menentukan manajemen penanganan Acute
Cholangitis
• Drainage Pilihan esensial
• Surgical approach  Tailor
Bergantung
1. Pasien
2. Surgeon
3. Sarana