Endoscopic drainage aborts endotoxaemia in acute cholangitis

Percutaneous transhepatic biliary drainage in patients at higher risk for adverse events: experience from a tertiary care referral center

BACKGROUND

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events.

MATERIAL

Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded.

RESULTS

During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed.

CONCLUSION

PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

Feasibility of initial endoscopic common bile duct stone removal in patients with acute cholangitis

AIM

To investigate the feasibility of initial endoscopic common bile duct (CBD) stone removal in patients with acute cholangitis (AC).

METHODS

A single-center, retrospective study was conducted between April 2013 and December 2014 and was approved by the Medical Ethics Committee at our institution. Written informed consent was obtained from each patient prior to the procedure. The cohort comprised 31 AC patients with CBD stones who underwent endoscopic biliary drainage (EBD) for naïve papilla within 48 h after AC onset. We retrospectively divided the participants into two groups: 19 patients with initial endoscopic CBD stone removal (initial group) and 12 patients with delayed endoscopic CBD stone removal (delayed group). We evaluated the feasibility of initial endoscopic CBD stone removal in patients with AC.

RESULTS

We observed no significant differences between the groups regarding patient characteristics. According to the assessments based on the Tokyo Guidelines, the AC severity of patients with initial endoscopic CBD stone removal was mild to moderate. The use of antithrombotic agents before EBD was less frequent in the initial group than in the delayed group (11% vs 58%, respectively; P = 0.004). All the patients underwent successful endoscopic CBD stone removal and adverse events did not differ significantly between the groups. The number of endoscopic retrograde cholangiopancreatography procedures was significantly lower in the initial group than in the delayed group [median (interquartile range) 1 (1-1) vs 2 (2-2), respectively; P < 0.001]. The length of hospital stay was significantly shorter for the initial group than for the delayed group [10 (9-15) vs 17 (14-20), respectively; P = 0.010].

CONCLUSION

Initial endoscopic CBD stone removal in patients with AC may be feasible when AC severity and the use of antithrombotic agents are carefully considered.

Endoscopic management of acute cholangitis according to the TG13

The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future.

Endotoxemia as a diagnostic tool for patients with suspected bacteremia caused by gram-negative organisms: a meta-analysis of 4 decades of studies

The clinical significance of endotoxin detection in blood has been evaluated for a broad range of patient groups in over 40 studies published over 4 decades. The influences of Gram-negative (GN) bacteremia species type and patient inclusion criteria on endotoxemia detection rates in published studies remain unclear. Studies were identified after a literature search and manual reviews of article bibliographies, together with a direct approach to authors of potentially eligible studies for data clarifications. The concordance between GN bacteremia and endotoxemia expressed as the summary diagnostic odds ratios (DORs) was derived for three GN bacteremia categories across eligible studies by using a hierarchical summary receiver operating characteristic (HSROC) method. Forty-two studies met broad inclusion criteria, with between 2 and 173 GN bacteremias in each study. Among all 42 studies, the DORs (95% confidence interval) were 3.2 (1.7 to 6.0) and 5.8 (2.4 to 13.7) in association with GN bacteremias with Escherichia coli and those with Pseudomonas aeruginosa, respectively. Among 12 studies of patients with sepsis, the proportion of endotoxemia positivity (95% confidence interval) among patients with P. aeruginosa bacteremia (69% [57 to 79%]; P=0.004) or with Proteus bacteremia (76% [51 to 91%]; P=0.04) was significantly higher than that among patients without GN bacteremia (49% [33 to 64%]), but this was not so for patients bacteremic with E. coli (57% [40 to 73%]; P=0.55). Among studies of the sepsis patient group, the concordance of endotoxemia with GN bacteremia was surprisingly weak, especially for E. coli GN bacteremia.

Endotoxin adsorption therapy using polymyxin B-immobilized fiber as a treatment for septic shock-associated severe acute cholangitis

The application of endotoxin adsorption therapy for severe acute cholangitis is controversial. We present a survival case of septic shock and multiple organ failure due to severe acute cholangitis. The patient was treated by endotoxin adsorption therapy using polymyxin B-immobilized fiber because he continued to remain in shock even after successful endoscopic nasobiliary drainage. The patient was an 84-year-old male diagnosed with acute cholangitis and acute pancreatitis who was transferred to our department because of shock and severe dyspnea. The patient had already developed acute respiratory failure, acute renal failure, and disseminated intravascular coagulation. We performed endoscopic nasobiliary drainage immediately, but the patient continued to remain in shock and plasma endotoxin level was markedly elevated at 133.6 pg/mL. Therefore, we performed direct hemoperfusion with polymyxin B-immobilized fiber. On starting the hemoperfusion, blood pressure and urine volume increased, and the plasma endotoxin level reduced considerably. On the basis of our experience in this case, we think that direct hemoperfusion with polymyxin B-immobilized fiber may be a useful modality in the management of severe acute cholangitis.

TG13 indications and techniques for biliary drainage in acute cholangitis (with videos)

The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Risk factors of organ failure in patients with bacteremic cholangitis

BACKGROUND

Bacteremic cholangitis carries a high mortality rate of up to 10 % in relation to organ failure (OF), including septic shock.

AIM

The purpose of this study was to elucidate predictive factors for OF in bacteremic cholangitis.

METHODS

A retrospective review of all patients diagnosed with acute cholangitis and proven bacteremia from 2003 to 2011 was performed. Comprehensive clinical and laboratory data of 211 patients were analyzed.

RESULTS

There were 42 cases (19.9 %) of OF and 5 deaths (2.4 %). In the multivariate logistic regression analysis, significant predictive factors for OF were successful biliary decompression, presence of extended-spectrum beta-lactamase organism (ESBL), higher total bilirubin, and higher blood urea nitrogen (BUN) level at admission with odds ratios (ORs) of 0.129, 6.793, 1.148, and 1.089, respectively. Subgroup analysis of 165 patients who underwent biliary decompression before an event (with OF: 20, without OF: 145) was performed to elucidate the risk factors for organ failure even after successful biliary drainage. Variables significantly associated with OF included ESBL and BUN (OR = 4.123 and 1.177, respectively). We developed a scoring system with regression coefficient of each significant variable. The organ failure score was calculated using the following equation: (1.4 × ESBL) + (0.2 × BUN). This scoring system for predicting OF was highly sensitive (85.0 %) and specific (83.4 %).

CONCLUSIONS

Biliary decompression, ESBL, total bilirubin, and BUN are prognostic determinants in patients with bacteremic cholangitis. An organ failure scoring system may allow clinicians to identify groups with poor prognosis even after successful biliary decompression.

Endotoxemia and mortality prediction in ICU and other settings: underlying risk and co-detection of gram negative bacteremia are confounders

INTRODUCTION

The interdependence between endotoxemia, gram negative (GN) bacteremia and mortality has been extensively studied. Underlying patient risk and GN bacteremia types are possible confounders of the relationship.

METHODS

Published studies with ≥ 10 patients in either ICU or non-ICU settings, endotoxemia detection by limulus assay, reporting mortality proportions and ≥ 1 GN bacteremia were included. Summary odds ratios (OR) for mortality were derived across all studies by meta-analysis for the following contrasts: sub-groups with either endotoxemia (group three), GN bacteremia (group two) or both (group one) each versus the group with neither detected (group four; reference group). The mortality proportion for group four is the proxy measure of study level risk within L'Abbé plots.

RESULTS

Thirty-five studies were found. Among nine studies in an ICU setting, the OR for mortality was borderline (OR <2) or non-significantly increased for groups two (GN bacteremia alone) and three (endotoxemia alone) and patient group one (GN bacteremia and endotoxemia co-detected) each versus patient group four (neither endotoxemia nor GN bacteremia detected). The ORs were markedly higher for group one versus group four (OR 6.9; 95% confidence interval (CI), 4.4 -to 11.0 when derived from non-ICU studies. The distributions of Pseudomonas aeruginosa and Escherichia coli bacteremias among groups one versus two are significantly unequal.

CONCLUSIONS

The co-detection of GN bacteremia and endotoxemia is predictive of increased mortality risk versus the detection of neither but only in studies undertaken in a non-ICU setting. Variation in GN bacteremia species types and underlying risk are likely unrecognized confounders in the individual studies.

Prophylaxis with ertapenem in patients with obstructive jaundice undergoing endoscopic retrograde cholangiopancreatography: safety, efficacy, and biliary penetration

BACKGROUND

Cholangitis and biliary sepsis are rare but serious complications of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study is to investigate the safety, efficacy, and biliary penetration of ertapenem, a newer carbapenem with a long half-life and broad-spectrum antimicrobial activity, for ERCP prophylaxis.

METHODS

Patients with obstructive jaundice without cholangitis received a single dose of ertapenem equal to 1 gram intravenously prior to ERCP. A 2-3 mL bile sample was collected after cannulation and prior to contrast injection. Patients were observed for 72 hours for cholangitis or drug-related adverse events. Biliary ertapenem levels were measured using high-performance liquid chromatography (HPLC).

RESULTS

Twenty-eight patients (ages 18-87 years, M/F ratio 1:1) were enrolled. Seven had no cholestasis and were included to study ertapenem penetration in unobstructed biliary trees. Cannulation was achieved in all patients. One patient (3.6%) with persistent intrahepatic stones developed cholangitis. No drug-related adverse events were noted. The mean time from ertapenem administration to bile collection was 60 ± 24 minutes. There was a significant negative correlation between serum bilirubin and biliary ertapenem levels (r = -0.542, P = 0.003) with the highest level (6.25 μg/mL) noted in unobstructed biliary systems.

CONCLUSION

Ertapenem appears to be a safe and effective prophylaxis in patients with obstructive jaundice undergoing ERCP despite a limited biliary penetration in patients with high-grade obstruction.

Does gram-negative bacteraemia occur without endotoxaemia? A meta-analysis using hierarchical summary ROC curves

The limulus assay for endotoxin has been studied as a method for the rapid identification of gram-negative (GN) bacteraemia. The chromogenic (C-limulus) version is 100-fold more sensitive to an internal endotoxin standard than the earlier gelation version (G-limulus). The objective of this analysis is to compare the concordance between GN bacteraemia and endotoxaemia as determined in clinical studies using either version of the limulus assay. The summary results for the diagnostic odds ratio (DOR), sensitivity and specificity were derived using a hierarchical summary receiver operating characteristic (HSROC) method of meta-analysis. Fifty-eight studies (25 G-limulus and 33 C-limulus) were included. Surprisingly, the mean DOR (4.9; 3-7.9 versus 10.7; 5.2-21.8) was inferior for studies using the C-limulus versus the original G-limulus version of the assay. Moreover, among studies limited to sepsis syndrome patients, the mean DOR remains poor at 4.2 (1.8-9.5). The proportion of GN bacteraemic patients for whom endotoxaemia is not detectable with either version of the limulus assay is >20% among the 58 studies overall, but >30% after the exclusion of studies with <25 patients and >20% among studies of patients with sepsis syndrome. These findings help to reconcile seemingly disparate study results.

Endoscopic biliary drainage by 7 Fr or 10 Fr stent placement in patients with acute cholangitis

BACKGROUND AND STUDY AIMS

Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of 7 Fr and 10 Fr stent placement for biliary drainage in patients with acute cholangitis.

PATIENTS AND METHODS

We recruited 40 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7 Fr or a 10 Fr straight flap stent placement during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and clinical outcome.

RESULTS

Of 40 patients, 20 were randomized to the 7 Fr stent group and 20 to the 10 Fr stent group. All patients had biliary obstruction due to stones in the common bile duct. Indications for biliary drainage were: fever >100.4 degrees F (n = 27), hypotension (n = 6), peritonism (n = 10), impaired consciousness (n = 8), and failure to improve with conservative management (n = 13). Biliary drainage was achieved in all patients. Abdominal pain, fever, jaundice, hypotension, peritonism, and altered sensorium improved after a median period of 3 days in both groups. Leukocyte counts became normal after a median time of 4 days in the 7 Fr stent group and 6 days in the 10 Fr stent group. There were no ERCP-related complications. There were no instances of occlusion or migration of stent. The success rates of biliary drainage in cholangitis were not affected by the size of stent used.

CONCLUSIONS

Biliary drainage by 7 Fr stent or 10 Fr stent is equally safe and effective treatment for patients with severe cholangitis.

The safety and effectiveness of endoscopic biliary decompression by plastic stent placement in acute suppurative cholangitis compared with nasobiliary drainage

BACKGROUND

Endoscopic retrograde biliary drainage (ERBD) by using a plastic stent is suggested to be as effective as endoscopic nasobiliary drainage (ENBD) for temporary biliary drainage in acute suppurative cholangitis (ASC). However, there are few studies that compared ERBD and ENBD in ASC.

OBJECTIVES

We compared the safety and efficacy of ERBD and ENBD for temporary biliary drainage in patients with ASC.

DESIGN

A case series.

SETTING

A tertiary-referral center.

PATIENTS AND INTERVENTIONS

Eighty patients with ASC underwent endoscopic biliary drainage with ENBD (n = 41) and ERBD (n = 39).

MAIN OUTCOME MEASUREMENT

Clinical outcomes, including complications related to ERCP and complications related to the type of the indwelling catheter.

RESULTS

Endoscopic biliary drainage was successfully achieved in all patients (100%). There were no significant differences in the demographic data between the 2 groups. There were no differences in the improvement of clinical and laboratory parameters between the 2 groups. Overall ERCP-related complication rates in the ENBD and ERBD groups were 31.7% and 38.5%, respectively (P = .527). Hyperamylasemia occurred in 18 patients, 12.2% in the ENBD group (5/41) and 33.3% in the ERBD group (13/39) (P = .024). Without endoscopic sphincterotomy (EST), there was no statistically significant difference in the incidence of hyperamylasemia between the 2 groups. However, with an EST, hyperamylasemia was more frequent in the ERBD group (12/28 [42.9%]) than in the ENBD group (3/27 [11.1%]) (P = .008).

LIMITATION

A single-center experience.

CONCLUSIONS

Endoscopic biliary decompression, whether by ERBD or ENBD, is an effective treatment for patients with ASC. However, more frequent hyperamylasemia with ERBD and EST deserves further evaluation.

Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines

Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment, and their condition has not improved. Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous transhepatic, and open methods. The clinical value of both endoscopic and percutaneous transhepatic drainage is well known. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization; therefore, this approach is advocated whenever it is applicable. In endoscopic drainage, either endoscopic nasobiliary drainage (ENBD) or tube stent placement can be used. There is no significant difference in the success rate, effectiveness, and morbidity between the two procedures. The decision to perform endoscopic sphincterotomy (EST) is made based on the patient's condition and the number and diameter of common bile duct stones. Open drainage, on the other hand, should be applied only in patients for whom endoscopic or percutaneous transhepatic drainage is contraindicated or has not been successfully performed. Cholecystectomy is recommended in patients with gallbladder stones, following the resolution of acute cholangitis with medical treatment, unless the patient has poor operative risk factors or declines surgery.

Endoscopic management of acute cholangitis in elderly patients

AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.

METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated.

RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupI, age < 60 years; group II, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in groupI. High fever (fever ≥ 38.0°C) was more common in groupI(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n = 34) and benign diseases in groupI(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0°C (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupIand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupI, 24 group II, stent: 64 groupI, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupI(2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupIcompared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4 ± 5.6, 7-30 d) than in groupIpatients (8.2 ± 2.4, 7-20 d).

CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.

The role of bacterial virulence and host factors in patients with Escherichia coli bacteremia who have acute cholangitis or upper urinary tract infection

We studied the pathogenic role of host and Escherichia coli virulence factors in the development of E. coli bacteremia in patients with acute cholangitis (AC) or upper urinary tract infection (UTI). Isolates recovered from 75 adult patients consecutively admitted to the hospital with E. coli bacteremia caused by AC (n=24) or upper UTI (n=51) were evaluated, as were 30 fecal strains isolated from healthy control individuals. Virulence genes of E. coli were detected by polymerase chain reaction analysis, including papG genes (classes I-III), sfa/foc, fimH, afa, hlyA, cnf1, and iutA. Our results show that biliary tract obstruction and urinary tract obstruction are important host factors for the development of E. coli bacteremia in patients with AC and upper UTI, respectively. With regard to E. coli virulence factors, the papG class II gene might play a more important role in the development of E. coli bacteremia in patients with upper UTI than in those with AC.

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial

BACKGROUND

Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones.

METHODS

Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39 degrees C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score).

RESULTS

Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group).

CONCLUSION

Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter.

Bacterial Cholangitis

The treatment of acute bacterial cholangitis requires broad-spectrum antibiotics to cover against gram-negative aerobic enteric organisms (Escherichia coli, Klebsiella species, and Enterobacter species), gram-positive Enterococcus and anaerobic bacteria (Bacteroides fragilis and Clostridium perfringens). Approximately 20% of patients with acute cholangitis fail to respond to conservative treatment with antibiotic therapy and require urgent biliary decompression, which is the mainstay of therapy. This is best accomplished by endoscopic retrograde cholangiopancreatography (ERCP) and placement of a nasobiliary drainage tube or a large bore (10 F or larger) indwelling plastic stent. Alternative therapy includes percutaneous transhepatic biliary drainage or surgical biliary decompression, but these carry a significantly higher morbidity and mortality. Supportive care includes intravenous fluid hydration to prevent renal failure and close monitoring of vital signs for determination of potential septicemia.

Urgent endoscopic nasobiliary drainage without fluoroscopic guidance: A useful treatment for critically ill patients with biliary obstruction

BACKGROUND

Endoscopic nasobiliary drainage (ENBD) is routinely performed under fluoroscopic control. This is a report of our experience with urgent ENBD without fluoroscopic guidance in critically ill patients.

METHODS

Twenty-six critically ill patients who underwent urgent ENBD for biliary obstruction were analyzed. ENBD was performed without fluoroscopic control because of high risk of transportation or inaccessibility of the x-ray facilities. A pig-tailed nasobiliary catheter was inserted into the bile duct with the help of a guidewire under endoscopic control to bypass the site of obstruction. Successful placement was confirmed by free flow of bile on aspiration via the nasobiliary catheter.

RESULTS

A nasobiliary catheter was successfully placed in 23 patients (88%). Adequate bile drainage was achieved in 20 patients with an overall success rate of 77%. There were no procedure-related complications. The mortality rate for patients with successful biliary drainage was 10% (2 of 20), in contrast to 83% (5 of 6) for the group in which drainage was unsuccessful.

CONCLUSIONS

Urgent ENBD is effective for patients with biliary obstruction. With experience, this procedure may be successfully performed in critically ill patients without fluoroscopic guidance at primary care hospitals or intensive care units where fluoroscopic facilities are not readily available.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

Biliary infection

Biliary infections are common conditions that can be life threatening. In the past, many of these conditions mandated emergency surgery, but advances in endoscopic and radiological techniques have allowed some of these to be managed in a minimally invasive fashion. Acute cholangitis is caused by infection in an obstructed biliary tree. Endoscopic drainage, together with broad-spectrum antibiotics, has replaced emergency common duct exploration and T-tube drainage as standard treatment. Oriental cholangitis, sclerosing cholangitis and AIDS-related cholangitis are some of the variants of cholangitis. Pyogenic liver abscesses complicating cholangitis can be managed by radiological percutaneous drainage. Close collaboration between surgeons, endoscopists and radiologists is the key to success in managing biliary infections.