Clinical evaluation of the Tokyo Guidelines 2013 for severity assessment of acute cholangitis

Acute suppurative terminal cholangitis: Clinical characteristics of a new subtype of acute cholangitis

BACKGROUND

Acute suppurative terminal cholangitis (ASTC) is rarer than acute obstructive cholangitis and is not well studied. To explore this subtype of acute cholangitis, we described our clinical experience with ASTC.

METHODS

We performed a retrospective review of patients with ASTC admitted to our center from September 2014 to August 2020. We analyzed their clinical characteristics, including etiology, clinical manifestations, imaging features, treatment and prognosis.

RESULTS

A total of 32 ASTC patients were included in the analysis. The majority of the patients had a history of biliary operations, and clinical manifestations were occult and atypical. The positive rate of bacterial culture was 46.9%. All the patients had typical imaging features on computed tomography and magnetic resonance imaging. Treatment with effective antibiotics was provided as soon as diagnosis was established. After treatment, most patients had a good outcome. Elevated levels of total bilirubin, aspartate aminotransferase, procalcitonin and gamma-glutamyltransferase were the characteristics of critically ill patients and were associated with relatively poor prognosis.

CONCLUSIONS

Our results demonstrated that ASTC should be recognized as a new subtype of acute cholangitis, and that earlier diagnosis and more personalized treatments are needed.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis

BACKGROUND

During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear.

AIM

To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC.

METHODS

We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use.

RESULTS

In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality.

CONCLUSION

Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

The Predictive Value of Different Laboratory Indicators Based on the 2018 Tokyo Guidelines for the Severity of Acute Cholangitis

BACKGROUND

This study evaluated the predictive value of different laboratory indicators for the severity of acute cholangitis (AC) according to the 2018 Tokyo Guidelines.

OBJECTIVES

We enrolled consecutive patients with a diagnosis of AC from June 2016 to May 2021. Serum procalcitonin (PCT) and C-reactive protein (CRP) levels, white blood cell counts, the neutrophil-lymphocyte ratio, and the platelet-lymphocyte ratio (PLR) were compared according to the severity of AC.

RESULTS

In total, 293 patients were enrolled in this study (mild, n = 172; moderate, n = 68; severe, n = 53). In receiver operating characteristic analyses, CRP was the best biomarker for differentiating mild and moderate AC (area under the curve [AUC] 0.66, 95% confidence interval [CI] 0.58-0.74). PCT was the best biomarker for differentiating mild and severe AC (AUC 0.80, 95% CI 0.74-0.86). Blood culture was performed in 117 patients (39.93%), 53 of whom (45.30%) had positive results. Regarding blood culture positivity, PLR was most predictive (AUC 0.85, 95% CI 0.78-0.92).

CONCLUSIONS

PCT can be used as a reliable predictor of severe AC. CRP was most predictive of moderate AC, whereas PLR was most predictive of blood culture positivity.

Proportion of Neutrophils in White Blood Cells as a Useful Marker for Predicting Bacteremic Acute Cholangitis

Objective A positive hemoculture in acute cholangitis is serious, but a blood culture result cannot be obtained at the initial diagnosis and so cannot be used for the severity assessment and decision-making concerning urgent/early biliary drainage. Accordingly, a predictor for bacteremia at the initial diagnosis of acute cholangitis would be particularly useful. We investigated the association between neutrophil proportions in white blood cell counts (%Neutro) and bacteremic acute cholangitis. Methods Of 166 patients with acute cholangitis who were diagnosed with the Tokyo Guidelines 2018/2013 from April 2015 to March 2017, a total of 94 underwent blood culture assessments and were divided into those with a positive hemoculture (n=48) and a negative hemoculture (n=46) and then compared. A receiver operating characteristic curve analysis was used to evaluate the predictive ability of %Neutro and other inflammatory markers. Results The %Neutro values were significantly higher in the positive hemoculture group than in the negative hemoculture group (91.7±4.0% vs. 82.5±9.0%, p<0.0001). A cut-off %Neutro value of 89.7% was strongly associated with bacteremia (area under the curve 0.86, sensitivity 77.1%, specificity 80.4%). A %Neutro of ≥89.7% was a predictor of a positive hemoculture in univariate (p<0.0001) and multivariate analyses (p<0.001). Patients with a %Neutro ≥89.7% needed early biliary drainage more frequently than others (30/46, 65.2% vs. 18/48, 37.5%, p=0.0063). Conclusion %Neutro is an independent predictor of bacteremia in patients with acute cholangitis and may contribute to decision-making concerning early biliary drainage.

Diagnostic value of the serum lactate level as a predictor of bacteremia in patients with acute cholangitis

BACKGROUND

Patients with acute cholangitis (AC) have increased mortality when associated with bacteremia. This study aimed to evaluate the predictive ability of serum lactate (Lac) for positive bacteremia in patients with acute cholangitis.

METHODS

In this single-center, retrospective study, 138 consecutive patients with AC were analyzed. Their blood samples were collected and Lac was measured.

RESULTS

A total of 50 patients showed grade I, 50 showed grade II, and 38 showed grade III severity according to the Tokyo Guidelines 2018. Positive bacteremia was observed in 71 patients, of which 15 showed grade I, 25 showed grade II, and 31 showed grade III severity. Logistic regression analysis showed that Lac was a significant predictor of bacteremia. The area under the curve of Lac and procalcitonin (PCT) for bacteremia were 0.737 and 0.780, respectively. The optimal cutoff values for bacteremia were 17 mg/dL and 2.8 ng/mL, with sensitivity of 69.0% and 68.3%, respectively. Sensitivity of Lac and PCT for bacteremia in grade I was 58.3% and 25.0%, respectively. Three patients died from AC, all of whom were positive for bacteremia and hyperlactatemia.

CONCLUSION

Lac is useful for predicting bacteremia in patients with AC.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

BACKGROUND

The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity.

AIM

To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.

METHODS

According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate.

RESULTS

Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.

CONCLUSION

ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BACKGROUND

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

METHODS

This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

RESULTS

Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

CONCLUSION

Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Unchanged mortality in patients with acute cholangitis despite an increase in malignant etiologies - a 25-year epidemiological study

Background and aims: Acute cholangitis (AC) is a rare but serious condition, with an incidence of 7.0 per 10,000 people and mortality rates up to 10%. The aim of this study was to describe changes in obstruction etiology, comorbidities, clinical factors, and mortality among AC patients during a 25-year period. Methods: Using a database of 11,563 consecutive ERCP-procedures performed from 1990-2015 at Odense University Hospital, we identified all AC cases during that period. Clinical and epidemiological data were collected from the database and the Danish Patient Registry. Association with 30-day mortality was investigated using multiple logistic regression analysis with adjustment for confounding factors. Results: In total, 775 consecutive and individual cases of AC were included. Among cases, 42% (n = 326) were of malignant etiology, with an increasing incidence over time (regression coefficient [95% CI]: 0.03 [0.01-0.04] per year; p = .01). Mean Charlson Comorbidity Index was 1.4, with an increase over time (regression coefficient [95% CI]: 0.04 [0.03-0.05] per year; p < .01). Malignant obstruction etiology was associated with 30-day mortality (OR [95% CI]: 1.11 [1.04-1.18]; p < .01). Overall 30-day mortality was 12% (n = 91). After adjustment for confounding factors, no significant changes in 30-day mortality were observed over time (OR [95% CI]: 1 [1-1.00]; p = .91 per year). Conclusion: Significant increases in the incidence of malignant obstruction etiology and severity of comorbidities among AC patients were observed during the study period. Despite those findings, 30-day mortality remained unchanged, potentially reflecting a general improvement in the management of AC.

Does surgical difficulty relate to severity of acute cholecystitis? Validation of the parkland grading scale based on intraoperative findings

BACKGROUND

The Parkland grading scale (PGS) was assessed to validate its correlation to severity of acute cholecystitis (AC).

METHODS

This study investigated the correlation between the PGS and Tokyo guidelines (TG) using multinomial logistic regression analysis in 177 patients with AC.

RESULTS

High PGS grades were related to higher C-reactive protein (p < 0.001) and frequent gangrenous cholecystitis (p < 0.001). The PGS and TG grades correlated with statistical significance (p < 0.001). Patients with PGS Grade 4 had a higher risk of moderate AC than those with Grade 3 (odds ratio: 4.4; 95% confidence interval [CI]: 1.2-15.6; p = 0.019). The PGS showed good predictive power for moderate or severe AC (area under the curve: 0.771; 95% CI: 0.700-0.842; p = 0.031).

CONCLUSION

The PGS is helpful to discriminate severity of AC. Patients with PGS Grade 4 or 5 have a high risk of moderate or severe AC.

Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model

OBJECTIVE

To determine the diagnostic accuracy of Tokyo guidelines (TG) 2018/2013 (TG18/TG13) and predictors of poor prognosis in acute cholangitis.

METHODS

Retrospective 1-year study of consecutive hospital admissions for acute cholangitis. Prognosis was defined in terms of 30 d in-hospital mortality.

RESULTS

Of the 183 patients with acute cholangitis, diagnostic accuracy based on Charcot's triad, TG07 and TG18/TG13 was 67.8, 86.9 and 92.3% (p < .001), respectively. Regarding severity based on TG18/TG13, 30.6% of cases were severe. A poor prognosis was found in 10.9% of patients. After multivariate analysis, systolic blood pressure <90 mmHg (OR 11.010; p < .001), serum albumin <3 g/dL (OR 1.355; p = .006), active oncology disease (OR 3.818; p = .006) and malignant aetiology of obstructive jaundice (OR 2.224; p = .021) were independent predictors of poor prognosis. The discriminative ability of the model with these four variables was high (AUROC 0.842; p < .001), being superior to TG18/TG13 (AUROC 0.693; p = .005).

CONCLUSIONS

TG18/TG13 showed high diagnostic accuracy in acute cholangitis. Compared with TG18/TG13, the simplified severity model ≥2 allows easy selection of patients who will benefit from admission to the intensive care unit and early biliary decompression.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Association between early ERCP and mortality in patients with acute cholangitis

BACKGROUND AND AIMS

Acute cholangitis (AC) is associated with high mortality of up to 10%. The association between timing of ERCP and mortality in patients with AC remains unclear. The aim of this study was to investigate whether early ERCP within 24 hours was associated with improved survival.

METHODS

All patients who underwent ERCP at Odense University Hospital, Denmark, between March 2009 and September 2016 were identified using a prospective ERCP database. Clinical data were collected from medical records. Patients fulfilling the Tokyo Guidelines 2013 criteria and for whom a detailed review of medical records revealed evidence of AC were included. We investigated the association between ERCP within 24 hours and 30-day mortality using logistic regression analysis with adjustment for confounding factors.

RESULTS

A total of 4066 consecutive patients underwent ERCP during the study period, and 166 patients fulfilled the inclusion criteria. Forty-eight patients (29%) underwent ERCP within 24 hours from the time of hospitalization, and 118 patients (71%) underwent later ERCP. Patients undergoing ERCP within 24 hours were younger (medians: 65 vs 73 years; P = .01) and had a higher heart rate (medians: 95 vs 90 beats/minute; P = .02). Overall 30-day mortality was 16% (n = 27). Mortality was 8% (n = 4) among patients undergoing early ERCP and 19% (n = 23) among patients undergoing later ERCP (P = .10). After adjustment for confounding factors, performance of ERCP within 24 hours was associated with lower 30-day mortality (odds ratio, 0.23; 95% confidence interval, 0.05-0.95; P = .04).

CONCLUSION

Our results indicate that early ERCP within 24 hours is associated with lower 30-day mortality in patients with AC.

Cholangitis: Diagnosis, Treatment and Prognosis

Cholangitis is a serious life-threatening situation affecting the hepatobiliary system. This review provides an update regarding the clinical and pathological features of various forms of cholangitis. A comprehensive search was performed in the PubMed, Scopus, and Web of Knowledge databases. It was found that the etiology and pathogenesis of cholangitis are heterogeneous. Cholangitis can be categorized as primary sclerosing (PSC), secondary (acute) cholangitis, and a recently characterized form, known as IgG4-associated cholangitis (IAC). Roles of genetic and acquired factors have been noted in development of various forms of cholangitis. PSC commonly follows a chronic and progressive course that may terminate in hepatobiliary neoplasms. In particular, PSC commonly has been associated with inflammatory bowel disease. Bacterial infections are known as the most common cause for AC. On the other hand, IAC has been commonly encountered along with pancreatitis. Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis. Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography and endoscopic ultrasonography comprise three of the modalities that are frequently exploited as both diagnostic and therapeutic tools. Biliary drainage procedures using these methods is necessary for controlling the progression of cholangitis. Promising results have been reported for the role of antibiotic treatment in management of AC and PSC; however, immunosuppressive drugs have also rendered clinical responses in IAC. With respect to the high rate of complications, surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed.

Procalcitonin is a useful biomarker to predict severe acute cholangitis: a single-center prospective study

BACKGROUND

Procalcitonin is being increasingly used to diagnose and grade acute systemic bacterial infection at an early stage of disease onset. The aim of this prospective study was to evaluate the usefulness of procalcitonin for severity grading of acute cholangitis on patient admission.

METHODS

Patients with acute cholangitis were prospectively enrolled. The severity of acute cholangitis was graded on the basis of the 2013 Tokyo guidelines (Japanese Society of Hepato-Biliary-Pancreatic Surgery, 2013). We compared the ability of procalcitonin level on admission to predict moderate/severe (vs mild) or severe (vs mild/moderate) acute cholangitis with the abilities of white blood cell (WBC) count and C-reactive protein (CRP) level.

RESULTS

Two hundred thirteen patients were analyzed, and the severity of acute cholangitis was graded as mild, moderate, and severe in 108, 76, and 29 patients respectively. Procalcitonin level, WBC count, and CRP level all increased significantly according to the severity. In the receiver operating characteristic analyses, the area under the curve for procalcitonin for severe acute cholangitis was 0.90 [95% confidence interval (CI) 0.85-0.96] and was significantly greater than that for WBC (0.62; 95% CI 0.48-0.76) and that for CRP (0.70; 95% CI 0.60-0.80). The optimal cutoff value for procalcitonin for prediction of severe acute cholangitis was 2.2 ng/mL (sensitivity 0.97; specificity 0.73; accuracy 0.77). The areas under the curve for procalcitonin, WBC, and CRP for moderate/severe acute cholangitis were not significantly different.

CONCLUSIONS

Procalcitonin predicted severe acute cholangitis better than conventional biomarkers. Severe cases for which urgent biliary drainage is indicated might be identified on admission on the basis of the cutoff values for procalcitonin suggested in this study.

Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study

BACKGROUND

The Tokyo Guidelines 2007 (TG07) first presented the diagnostic and severity grading criteria for acute cholangitis. Subsequently updated in 2013, the Tokyo Guidelines (TG13) have been widely adopted throughout the world as global standard guidelines. We set out to verify the efficacy of these TG13 criteria in an international multicenter study.

METHODS

We reviewed 6,063 patients who were clinically diagnosed with acute cholangitis in Japan and Taiwan over a 2-year period. The TG13 diagnostic and severity grading criteria were retrospectively applied, and 30-day mortality was investigated.

RESULTS

A diagnosis of acute cholangitis was made in 5,454 (90.0%) patients on the basis of the TG13 criteria, and in 4,815 (79.4%) patients on the basis of the TG07 criteria. The 30-day mortality rates of patients with Grade III, Grade II, and Grade I were 5.1%, 2.6%, and 1.2%, respectively, and increased significantly along with disease severity. The mortality rate in the 1,272 Grade II cases where urgent or early biliary drainage was performed was 2.0% (n = 25), which was significantly lower than that of 3.7% (n = 28) in the other 748 cases.

CONCLUSION

By using the TG13 diagnostic and severity grading criteria, more patients with possible acute cholangitis can be diagnosed, and patients whose prognosis can potentially be improved by early biliary drainage can be identified. The TG13 criteria are appropriate and useful for clinical practice.

Cholangiohepatitis in Dairy Cattle: 13 Cases

Background

The signalment, clinicopathologic, bacteriological, histopathological, ultrasonographic characteristics, and the treatment and outcomes of adult cattle with cholangiohepatitis are poorly defined.

Animals

Thirteen Holstein cows with cholangiohepatitis.

Methods

Retrospective study of medical records of cattle admitted to the CHUV and the AVC between 1992 and 2012 and 2000 and 2012, respectively, for cattle older than 3 months of age with a histopathological diagnosis of cholangiohepatitis. Cholangiohepatitis was defined as the presence of portal inflammation surrounding or infiltrating bile ducts, with or without epithelial damage, and extending into the adjacent lobules.

Results

At the time of diagnosis of cholangiohepatitis, cows had decreased appetite (n = 7) or were anorectic (n = 6), had fever (n = 5), and had tachycardia (n = 8). Icterus was detected in 5 cows. Yellow discoloration was identified on the skin of the udder (n = 3), conjunctiva (n = 2), and vulva (n = 1). There was leukocytosis (n = 6), neutrophilia (n = 9), and hyperfibrinogenemia (n = 8). Alteration in the serum biochemistry profile included hyperglobulinemia (n = 8), hypoalbuminemia (n = 10), increased activity of GGT (n = 12), AST (n = 8), and ALP (n = 10), and hyperbilirubinemia (n = 10). Histopathological diagnosis included mild, subacute, nonsuppurative cholangiohepatitis (n = 4), mild suppurative cholangiohepatitis (n = 4), mild mixed (neutrophilic and lymphocytic) cholangiohepatitis (n = 3), and moderate, chronic, nonsuppurative cholangiohepatitis (n = 1). Six cows were discharged from the hospital, and 7 were euthanized.

Conclusions and Clinical Importance

Cholangiohepatitis is a rare condition in adult cattle. Antemortem diagnosis can be challenging because clinical signs are unspecific.

Controversy and progress for treatment of acute cholangitis after Tokyo Guidelines (TG13)

Tokyo Guideline 2013 (TG13) is an international guideline for the diagnosis, classification and treatment of acute cholangitis. Progress and controversy for the two years after TG13 was summarized. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are both effective imaging tests for common bile duct (CBD) stones. More factors e.g. obesity may be involved in severity assessment. Initiation of broad-spectrum antibiotics addressing the typical Gram-negative enteric bacteria spectrum and early biliary drainage are the mainstay therapeutic options. Early laparoscopic exploration is also an option for stone-related nonsevere acute cholangitis besides endoscopic retrograde cholangial or percutaneous transhepatic cholangial drainage. Surgical biliary drainage should be avoided in severe cholangitis.

Clinical efficacy of emergency endoscopy in elderly patients with acute cholangitis

AIM: To evaluate the clinical efficacy of emergency endoscopy in elderly patients with acute cholangitis (AC).

METHODS: Clinical data for 148 elderly patients with acute cholangitis who underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) from March 2013 to July 2014 at Tianjin Nankai Hospital were retrospectively analyzed.

RESULTS: Of the 148 cases, 141 underwent successful emergency endoscopy, of whom 65 had stone removal in the first session, and 74 had significant relief of clinical symptoms after endoscopic nasobiliary drainage (ENBD). Two patients died. Of the 141 case who underwent successful ERCP, 7 developed bleeding, and 2 developed pancreatitis after ERCP.

CONCLUSION: Emergency endoscopy is a safe and effective method for the treatment of elderly patients with acute cholangitis. In experienced digestive endoscopy centers, emergency endoscopy can be used as a preferred treatment for elderly patients with acute cholangitis.

Acute Bacterial Cholangitis

Background

Acute bacterial cholangitis for the most part owing to common bile duct stones is common in gastroenterology practice and represents a potentially life-threatening condition often characterized by fever, abdominal pain, and jaundice (Charcot's triad) as well as confusion and septic shock (Reynolds' pentad).

Methods

This review is based on a systematic literature review in PubMed with the search items ‘cholangitis’, ‘choledocholithiasis’, ‘gallstone disease’, ‘biliary infection’, and ‘biliary sepsis’.

Results

Although most patients respond to empiric broad-spectrum antibiotic treatment, timely endoscopic biliary drainage depending on the severity of the disease is required to eliminate the underlying obstruction. Specific recommendations have been derived from the Tokyo guideline working group consensus 2006 and its update in 2013, albeit poorly evidence-based, providing a comprehensive overview of diagnosis, classification, risk stratification, and treatment algorithms in acute bacterial cholangitis.

Conclusion

Prompt clinical recognition and accurate diagnostic workup including adequate laboratory assessment and (aetiology-oriented) imaging are critical steps in the management of cholangitis. Treatment is directed at the two major interrelated pathophysiologic components, i.e. bacterial infection (immediate antimicrobial therapy) and bile duct obstruction (biliary drainage). As for the latter, transpapillary endoscopic drainage by stent or nasobiliary drain and/or same-session bile duct clearance, depending on individual disease severity, represent first-line treatment approaches.