Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center

Internal versus external biliary drainage in malignant biliary obstructions: is there a difference in the rate of infection?

BACKGROUND

Percutaneous biliary drainage is a frequently used method to provide biliary decompression in patients with biliary obstruction.

PURPOSE

To investigate the between drainage type and infection risk in patients treated with internal-external and external biliary drainage catheterization for malignant biliary obstruction.

MATERIAL AND METHODS

A total of 410 patients with malignant biliary obstruction who underwent internal-external or external biliary drainage catheterization between January 2012 and October 2016 were retrospectively evaluated. We investigated the correlation between percutaneous biliary drainage technique and infection frequency by evaluating patients with clinical findings, bile and blood cultures, complete blood counts, and blood biochemistry.

RESULTS

There was no statistically significant difference between the selected patient groups (internal-external or external biliary drainage catheter placed) in terms of age, sex, primary diagnosis, receiving chemotherapy, catheter sizes, and outpatient-patient status. After catheterization, catheter-related infection was observed in 49 of 216 (22.7%) patients with internal-external and 18 of 127 (14.2%) patients with external biliary drainage catheters, according to the defined criteria. There was no difference in infection rate after the biliary drainage in the two groups (P > 0.05). There was also no difference concerning frequently proliferating microorganisms in bile cultures.

CONCLUSION

Internal-external biliary drainage catheter placement does not bring an additional infection risk for uninfected cholestatic patients whose obstruction could be passed easily in the initial drainage.

Risk factors for post-endoscopic retrograde cholangiopancreatography cholangitis in patients with hepatic alveolar echinococcosis-an observational study

BACKGROUND

Hepatic alveolar echinococcosis (HAE) is considered to be one of the most deadly chronic parasitic diseases in the world. We have shown that the incidence of cholangitis in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) was increased significantly. On this finding, we carried out, a preliminary study on the risk factors for cholangitis after ERCP.

AIMS

To retrospectively detect the risk factors for post-ERCP cholangitis in patients with biliary tract affected by HAE.

METHODS

The study included data from 51 cases of AE who had undergone therapeutic ERCP between January 2015 and December 2019. Demographic and treatment data were extracted from the medical records, and the association between potential risk factors and the development of post-ERCP cholangitis was evaluated using a collected database.

RESULTS

There were five cases of mild cholangitis after ERCP (Tokyo criteria), and no moderate or severe cholangitis occurred. The incidence rate of cholangitis after ERCP was 9.8%. Univariate analysis showed hilar bile duct stenosis (p = .016), endoscopic retrograde biliary drainage (p = .007), a stent diameter ≥8.5 Fr (p = .000) and single stent implantation (p = .010) were risk factors for post -ERCP cholangitis. All cases of cholangitis improved under conservative treatment.

CONCLUSION

Patients with hilar bile duct compression or endoscopic retrograde biliary drainage appeared to be more likely to develop post-ERCP cholangitis. The number and diameter of biliary stents may influence post-ERCP cholangitis. Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors for screening. KEY MESSAGESMany studies reported the post-ERCP complications in patients with hepatic alveolar echinococcosis and found that the incidence of post-ERCP cholangitis was significantly high. Therefore, we conducted a preliminary study on the risk factors of postoperative cholangitis in patients who underwent ERCP.The incidence rate of cholangitis after ERCP was 9.8%. We found that hilar bile duct stenosis, and endoscopic retrograde biliary drainage, were risk factors for cholangitis, and stent diameter and the number of stent implantation may influence the incidence rate of cholangitis after ERCP.Sample size and clinical heterogeneity are two insurmountable difficulties, and a larger sample size needs to be collected to verify the risk factors of screening.

Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients

AIM

To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients.

MATERIALS AND METHODS

We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed.

RESULTS

Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2-3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis).

CONCLUSIONS

Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.

Guidelines for Management of Urgent Symptoms in Patients with Cholangiocarcinoma and Biliary Stents or Catheters using the Modified RAND/UCLA Delphi Process

Background: Patients with cholangiocarcinoma often have indwelling biliary stents or catheters which are prone to obstructions and/or infections; studies show that 20–40% present with fever and/or jaundice requiring urgent treatment in the outpatient setting for which there are no uniform guidelines. The goal was to develop an expert panel consensus on this topic using the modified RAND/UCLA Delphi process to rate treatment appropriateness. Methods: Thirteen expert physicians from relevant specialties, geography, and practice settings were recruited for the panel. Patient scenarios were developed and panelists rated the therapies before and after a face-to-face discussion. The appropriateness of various therapies was rated on a scale from 1–9 and classified as appropriate, inappropriate, or uncertain. Scenarios with greater than 2 (>2) ratings of 1–3 (inappropriate) and greater than 2 (>2) ratings of 7–9 (appropriate) were considered to have disagreement and were not assigned an appropriateness rating. Results: Panelists were from all US regions and the UK (8%) and had practiced for a mean 16.5 years (4–33 years). Panelists rated 480 scenarios before the meeting and re-rated 288 of the clinical scenarios after the meeting. The panelists agreed that ongoing treatment with chemotherapy did not influence decision-making and, therefore, 192 scenarios were excluded from the final list. Disagreement decreased from 37.5% before to 10.4% after the meeting. Consensus on stent/tube manipulation and inpatient antibiotic therapy was obtained and summarized in patients as “appropriate” or “maybe appropriate” based on a patient’s bilirubin level at presentation. Conclusions: The Delphi process produced consensus guidelines to fill an unmet need in the urgent management of ascending cholangitis in patients with cholangiocarcinoma.

Risk Prediction for Early Biliary Infection after Percutaneous Transhepatic Biliary Stent Placement in Malignant Biliary Obstruction

PURPOSE

To establish a nomogram for predicting the occurrence of early biliary infection (EBI) after percutaneous transhepatic biliary stent (PTBS) placement in malignant biliary obstruction (MBO).

MATERIALS AND METHODS

In this multicenter study, patients treated with PTBS for MBO were allocated to a training cohort or a validation cohort. The independent risk factors for EBI selected by multivariate analyses in the training cohort were used to develop a predictive nomogram. An artificial neural network was applied to assess the importance of these factors in predicting EBI. The predictive accuracy of this nomogram was determined by concordance index (c-index) and a calibration plot, both internally and externally.

RESULTS

A total of 243 patients (training cohort: n = 182; validation cohort: n = 61) were included in this study. The independent risk factors were length of obstruction (odds ratio [OR], 1.061; 95% confidence interval [CI], 1.013-1.111; P = .012), diabetes (OR, 5.070; 95% CI, 1.917-13.412; P = .001), location of obstruction (OR, 2.283; 95% CI, 1.012-5.149; P = .047), and previous surgical or endoscopic intervention (OR, 3.968; 95% CI, 1.709-9.217; P = .001), which were selected into the nomogram. The c-index values showed good predictive performance in the training and validation cohorts (0.792 and 0.802, respectively). The optimum cutoff value of risk was 0.25.

CONCLUSIONS

The nomogram can facilitate the early and accurate prediction of EBI in patients with MBO who underwent PTBS. Patients with high risk (> 0.25) should be administered more effective prophylactic antibiotics and undergo closer monitoring.

Clinical Impact of Percutaneous Transhepatic Insertion of Metal Biliary Endoprostheses for Palliation of Jaundice and Facilitation of Chemotherapy

OBJECTIVE

To describe the technique and report on the clinical benefit of percutaneous transhepatic metal biliary endoprosthesis (TMBE) placement for the palliation of malignant biliary obstruction (MBO).

MATERIALS AND METHODS

This is a retrospective single-center case series of 31 TMBE placements between October 2007 and October 2011 in 29 patients with inoperable MBO who failed endoscopic drainage and were not candidates for surgical resection. The mean age was 66.4 years. Eastern Cooperative Oncology Group performance scores were ≤2 in all patients. Data on procedural success, clinical and radiologic markers of stent patency, procedure-related complications, return to medically treatable status, benefit from chemotherapy, and survival were recorded.

RESULTS

All TMBE procedures were successful with no major procedure-related complications, and all patients improved clinically. Mean preprocedural and postprocedural bilirubin concentrations were 228.9±138.4 and 39.9.0±33.6 μmol/L, respectively (P<0.0001). Mean overall survival and occlusion-free survival were 9.355±2.425 months (95% confidence interval [4.60-14.12]) and 4.678±0.720 months (95% confidence interval [3.27-6.09]), respectively. Chemotherapy was initiated or reinstated in 16 patients (55%), 7 of whom (44%) demonstrated stable disease or partial response. Three patients were lost to follow-up.

CONCLUSIONS

TMBE provides acceptable palliation for patients with inoperable MBO who have failed endoscopic drainage. Stents appear to remain patent for the remainder of the patient's life in most cases and may facilitate the first induction or reinstatement of chemotherapy with further clinical response in some patients.

Risk Factors for Immediate and Delayed-Onset Fever After Percutaneous Transhepatic Biliary Drainage

OBJECTIVES

To prospectively investigate the pre and intra-procedural risk factors for immediate (IF) and delayed-onset (DOF) fever development after percutaneous transhepatic biliary drainage (PTBD).

METHODS

Institutional review board approval and informed patient consent were obtained. Between February 2013 and February 2014, 97 afebrile patients (77 at the Sapienza University of Rome, Italy and 20 at the Sun Yat-sen University of Guangzhou, China) with benign (n = 31) and malignant (n = 66) indications for a first PTBD were prospectively enrolled. Thirty pre- and intra-procedural clinical/radiological characteristics, including the amount of contrast media injected prior to PTBD placement, were collected in relation to the development of IF (within 24 h) or DOF (after 24 h). Fever was defined as ≥37.5 °C. Binary logistic regression analysis was used to assess independent associations with IF and DOF.

RESULTS

Fourteen (14.4%) patients developed IF and 17 (17.5%) developed DOF. At multivariable analysis, IF was associated with pre-procedural absence of intrahepatic bile duct dilatation (OR 63.359; 95% CI 2.658-1510.055; P = 0.010) and low INR (OR 4.7 × 10(-4); 95% CI 0.000-0.376; P = 0.025), while DOF was associated with unsatisfactory biliary drainage at the end of PTBD (OR 4.571; 95% CI 1.161-17.992; P = 0.030).

CONCLUSIONS

The amount of contrast injected is not associated with post-PTBD fever development. Unsatisfactory biliary drainage at the end of PTBD is associated with DOF, suggesting that complete biliary tree decompression should be pursued within the first PTBD. Patients with unsatisfactory drainage and those with the absence of pre-procedural intrahepatic bile duct dilatation, which is associated with IF, require tailored post-PTBD management.

Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management

Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.

Percutaneous Management of Malignant Biliary Obstruction

Malignancy resulting in impaired biliary drainage includes a number of diagnoses familiar to the interventional radiologist. Adequate drainage of such a system can significantly improve patient quality of life, and can facilitate the further treatment options and care of such patients. In the setting of prior instrumentation, cholangitis can present as an urgent indication for drainage. Current initial interventional management of malignant biliary duct obstruction frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations in performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with malignant biliary duct obstruction.

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.

Internal-external percutaneous transhepatic biliary drainage for patients with malignant obstructive jaundice

PURPOSE

To evaluate the effect of internal-external percutaneous transhepatic biliary drainage (IEPTBD) for patients with malignant obstructive jaundice.

METHODS

During the period of January 2008 and July 2013, internal-external drainage was performed in 42 patients with malignant obstructive jaundice. During the procedure, if the guide wire could pass through the occlusion and into the duodenum, IEPTBD was performed. External drainage biliary catheter was placed if the occlusion was not crossed. Newly onset of infection, degree of bilirubin decrease and the survival time of patients were selected as parameters to evaluate the effect of IEPTBD.

RESULTS

Twenty newly onset of infection were recorded after procedure and new infectious rate was 47.6%. Sixteen patients with infection (3 before, 13 after drainage) were uncontrolled after procedure, 12 of them (3 before, 9 after drainage) died within 1 month. The mean TBIL levels declined from 299.53 umol/L before drainage to 257.62 umol/L after drainage, while uninfected group decline from 274.86 umol/L to 132.34 umol/Lp (P < 0.5). The median survival time for uninfected group was 107 days, and for infection group was 43 days (P < 0.05).

CONCLUSIONS

The IEPTBD drainage may increase the chance of biliary infection, reduce bile drainage efficiency and decrease the long-term prognosis, and the external drainage is a better choice for patients with malignant obstructive jaundice need to biliary drainage.

Biliary issues in the bariatric population

Biliary disease is common in the obese population and increases after bariatric surgery. This article reviews management of the gallbladder at the time of bariatric surgery, as well as imaging modalities in the bariatric surgery population and prevention of lithogenesis in the rapid weight loss phase. In addition, diagnosis and treatment options for biliary diseases are discussed, including laparoscopic-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography in the patient having bariatric surgery.

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

PURPOSE

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

MATERIALS AND METHODS

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

RESULTS

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%.

CONCLUSIONS

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Complications of endoscopic and radiologic investigation of biliary tract disorders

The investigation and treatment of disorders of the human biliary tree depend considerably on invasive endoscopic and radiologic procedures. These are associated with a significant risk of complications, some of which can be fatal. This review looks at these complications through the lens of 40 years of publications in the medical literature, and identifies the strengths and weaknesses of their current classification, diagnosis, and treatment.

Cholangitis prevention in endoscopic Klatskin tumor palliation: air cholangiography technique

INTRODUCTION

Endoscopic biliary drainage is the treatment of choice for inoperable hilar cholangiocarcinoma (so-called Klatskin tumor). Cholangitis is the main complication post-endoscopic retrograde cholangiopancreatography (ERCP) in Klatskin patients, specially when medium contrast is injected into biliary tree that could not be subsequently drained. Bacterial cholangitis is the principal cause of mortality in these patients. The aim of this study is to analyze cholangitis rate resulting from the use of air versus iodine contrast to obtain cholangiography during ERCP.

METHODS

In 9 years, 188 inoperable Klatskin patients were recruited and divided into two groups: iodine (A) or air (B) contrast cholangiography, respectively. We used air or iodine contrast to obtain cholangiography before hilar stricture stenting. We retrospectively compared these data in both groups.

RESULTS

The group B had a significant lower rate of cholangitis than group A in Bismuth type II (p < 0.05), in Bismuth type III (p < 0.05), and in the Bismuth type IV population (p < 0.05).

CONCLUSION

The air contrast cholangiography is a safe and effective method, and it appears justified as a routine procedure to prevent or reduce the risk of post-ERCP cholangitis, specially in Klatskin patients (p < 0.005).

Diagnosis and management of acute cholangitis

Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.

Percutaneous transhepatic biliary drainage

Over the past three decades, endoscopic and percutaneous biliary drainage have become readily available in most hospital settings and these minimally invasive techniques have revolutionized the treatment of patients with biliary obstruction. In the past, treatment of biliary obstruction had required surgery under general anesthesia and an extended hospital stay. Currently, the same patient can most often be treated either endoscopically as an outpatient or during a short hospital stay after percutaneous drainage under moderate sedation. This article reviews the indications and technique of percutaneous transhepatic cholangiography and biliary drainage.

Approach to the patient who has suspected acute bacterial cholangitis

Table 4 gives summary recommendations concerning the major decisions that are related to the diagnosis and management of suspected acute bacterial cholangitis. All of these decisions have to be made within the context of disease severity, degree of diagnostic uncertainty, and associated comorbidity. Although these recommendations are based on evidence, there are few randomized controlled trials. Antibiotics that cover gram negatives and anaerobes, along with fluid and electrolyte correction, frequently stabilize the patient. Imaging studies frequently confirm the diagnosis and identify the location and etiology of the obstruction. With or without a definitive diagnosis, ERCP or PTC can be done emergently to establish drainage to control sepsis. Although endoscopic and percutaneous drainage techniques have lower morbidity and mortality than does emergent surgical decompression, optimal management of this potentially life-threatening condition requires close cooperation between the gastroenterologist, radiologist, and surgeon.