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Bartoli A, Cursaro C, Seferi H, Andreone P. Secondary Sclerosing Cholangitis After SARS-CoV2: ICU Ketamine Use or Virus-Specific Biliary Tropism and Injury in the Context of Biliary Ischemia in Critically Ill Patients? Hepat Med 2023; 15:93-112. [PMID: 37547355 PMCID: PMC10404108 DOI: 10.2147/hmer.s384220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/12/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose From the beginning of the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV2) pandemic, different cases of a cholangiopathy with features of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) have been reported. Patients developing it are generally recovering from severe Coronavirus disease 19 (COVID-19) and required intensive care unit (ICU) admission and mechanical ventilation. Many of them have been administered with ketamine during their ICU stay. The pathogenesis of this novel disease is still debated, and, since prognosis is poor, efforts are needed in order to better understand it. Patients and Methods In this review, we focused our attention on COVID-19 SSC clinical, imaging, and histology findings in order to clarify the different pathogenetic options, particularly in regard of the ischemic-direct viral damage and ketamine-related theories, beginning with a recapitulation of SSC-CIP and ketamine-induced cholangiopathy in abusers. The research has been conducted using PubMed and Google Scholar databases. Key-words were "Secondary Sclerosing Cholangiopathy", "SSC-CIP", "Secondary Sclerosing Cholangiopathy in critically ill patients", "Ketamine and cholangiopathy", "Ketamine abusers and liver disease", "Ketamine-related cholangiopathy", "SARS-CoV2 infection and liver disease", "post Covid-19 secondary sclerosing cholangitis", "Covid-19 cholangiopathy". Results Many authors, based on the clinical, histological, imaging, and prognostic features of the disease, have pointed out the similarities between post COVID-19 SSC and SSC-CIP; however, peculiar features in the former were not previously observed. Therefore, a direct viral cytopathic action and SARS-CoV2-related coagulopathy are considered the most likely causes. On the other hand, ketamine, with the available data, cannot be surely linked as the main determinant cause of cholangiopathy. Moreover, ketamine-induced cholangitis (KIC) presentation is different from post COVID-19 SSC. Its role as a cofactor precipitating the disease cannot be ruled out. Conclusion Post COVID-19 SSC is a rare clinical entity following severe COVID-19 disease. The most accepted theory is that a sum of different insults determines the disease: biliary ischemia, direct viral damage, toxic bile, possibly worsened by ketamine and hyperinflammation due to the cytokine storm. Given the severe prognosis of the disease, with persistent cholangiopathy, organ failure, and orthotopic liver transplantation (OLT), further study on this novel clinical entity is needed.
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Affiliation(s)
- Alessandra Bartoli
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
- Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Carmela Cursaro
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Hajrie Seferi
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Chief of Division of Internal Medicine and metabolism, Department of Internal Medicine, University Hospital of Modena, Modena, Italy
- Chief of Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
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Stahl K, Klein F, Voigtländer T, Großhennig A, Book T, Müller T, Wree A, Kuellmer A, Weigt J, Dechene A, Wedi E, Kandulski A, Lange CM, Holzwart D, von Witzendorff D, Ringe KI, Wedemeyer H, Heidrich B. BISCIT: Biliary interventions in critically ill patients with secondary sclerosing cholangitis-a study protocol for a multicenter, randomized, controlled parallel group trial. Trials 2023; 24:247. [PMID: 37004078 PMCID: PMC10067228 DOI: 10.1186/s13063-023-07260-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Progress of cholangitis to cholangiosepsis is a frequent observation in patients with secondary sclerosing cholangitis in critically ill patients (SSC-CIP). Adequate biliary drainage may reduce episodes of cholangiosepsis and therefore stabilize liver function and improve survival. The primary objective of the BISCIT study is to demonstrate that scheduled biliary interventions will reduce incidence of cholangiosepsis, liver transplantation, or death in patients with SSC-CIP. METHODS A total of 104 patients will be randomized at ten study sites. Patients with SSC-CIP, confirmed by endoscopic retrograde cholangiography (ERC), will be randomized 1:1 either in the intervention group which will be treated with scheduled biliary interventions (i.e., therapeutic ERC) every 8 weeks for 6 months or in the control group which will receive standard of care. The randomization will be stratified by center. The composite primary efficacy endpoint is defined as (1) occurrence of death, (2) necessity of liver transplantation, or (3) occurrence of cholangiosepsis within 6 months following randomization. DISCUSSION Prospective evaluation of endoscopic treatment procedures is urgently needed to establish an evidence-based therapeutic treatment algorithm in SSC-CIP. A positive trial result could change the current standard of care for patients with SSC-CIP. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT05396755, date of registration: May 31, 2022, last update: May 31, 2022).
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Affiliation(s)
- Klaus Stahl
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Carl-Neuberg Strasse 1, 30625, Hannover, Germany.
| | - Friederike Klein
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Carl-Neuberg Strasse 1, 30625, Hannover, Germany
| | - Torsten Voigtländer
- Department of Gastroenterology, Clementinenkrankenhaus Hannover, Hannover, Germany
| | - Anika Großhennig
- Department of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Thorsten Book
- Department of Gastroenterology, Clementinenkrankenhaus Hannover, Hannover, Germany
| | - Tobias Müller
- Department of Hepatology and Gastroenterology, Charite University Medicine Berlin, Campus Charite Mitte/Campus Virchow Clinic, Berlin, Germany
| | - Alexander Wree
- Department of Hepatology and Gastroenterology, Charite University Medicine Berlin, Campus Charite Mitte/Campus Virchow Clinic, Berlin, Germany
| | - Armin Kuellmer
- Clinic for Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Freiburg, Germany
| | - Jochen Weigt
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Alexander Dechene
- Department of Gastroenterology and Endocrinology, Hospital Nurnberg, Nurnberg, Germany
| | - Edris Wedi
- Department of Gastroenterology, Gastro-Oncology and Interventional Endoscopy, Sana Hospital Offenbach, Offenbach, Germany
| | - Arne Kandulski
- Department of Gastroenterology, Endocrinology, Infectious Diseases and Rheumatology, University Hospital Regensburg, Regensburg, Germany
| | - Christian M Lange
- Department of Gastroenterology and Hepatology, University Hospital Munich (LMU), Munich, Germany
| | - Dennis Holzwart
- Department of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Dorothee von Witzendorff
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Carl-Neuberg Strasse 1, 30625, Hannover, Germany
| | - Kristina I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
- Zentrum Klinische Studien (ZKS), Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Carl-Neuberg Strasse 1, 30625, Hannover, Germany
| | - Benjamin Heidrich
- Hannover Medical School, Department of Gastroenterology, Hepatology and Endocrinology, Carl-Neuberg Strasse 1, 30625, Hannover, Germany
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Möller K, Braden B, Culver EL, Jenssen C, Zadeh ES, Alhyari A, Görg C, Ignee A, Hocke M, Dong Y, Sun S, Faiss S, Dietrich CF. Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging. Endosc Ultrasound 2023; 12:181-199. [PMID: 36588352 PMCID: PMC10237613 DOI: 10.4103/eus-d-22-00208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/08/2022] [Indexed: 01/01/2023] Open
Abstract
Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.
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Affiliation(s)
- Kathleen Möller
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Emma L. Culver
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland GmbH, Strausberg, Wriezen, Germany
- Brandenburg Institute of Clinical Medicine at Medical University Brandenburg, Neuruppin, Germany
| | - Ehsan Safai Zadeh
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Amjad Alhyari
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Christian Görg
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Marburg, Germany
| | - André Ignee
- Department of Internal Medicine – Gastroenterology and Rheumatology; Klinikum Wuerzburg Mitte, Wuerzburg, Germany
| | - Michael Hocke
- Medical Department II, Helios Klinikum Meiningen, Meiningen, Germany
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyu Sun
- Department of Endoscopy Center, Shengjing Hospital of China Medical University, Liaoning Province, China
| | - Siegbert Faiss
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Christoph F. Dietrich
- Department of Internal Medicine (DAIM), Hirslanden Private Hospital, Beau Site, Salem und Permanence, Bern, Switzerland
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A Randomized, Dose-Finding, Proof-of-Concept Study of Berberine Ursodeoxycholate in Patients With Primary Sclerosing Cholangitis. Am J Gastroenterol 2022; 117:1805-1815. [PMID: 36327436 DOI: 10.14309/ajg.0000000000001956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a fibroinflammatory disease of the bile ducts leading to cirrhosis and hepatic decompensation. There are no approved pharmaceutical therapies for PSC. Berberine ursodeoxycholate (HTD1801) is an ionic salt of berberine and ursodeoxycholic acid with pleiotropic mechanisms of action. METHODS An 18-week proof-of-concept study was conducted to assess the safety and efficacy of HTD1801 in PSC. This study had three 6-week periods: (i) a placebo-controlled period, (ii) a treatment extension period, and (iii) a randomized treatment withdrawal period. The primary end point was change from baseline in alkaline phosphatase (ALP) at week 6. RESULTS Fifty-five patients were randomized and treated; 35 (64%) had inflammatory bowel disease and 22 (40%) had previously received ursodeoxycholic acid. Patients were initially randomized to placebo (n = 16), HTD1801 500 mg BID (n = 15), or HTD1801 1000 mg BID (n = 24). At baseline, mean (range) ALP values were 414 U/L (138-1,048), 397 U/L (237-773), and 335 U/L (122-882) for the placebo, HTD1801 500 mg BID, and HTD1801 1,000 mg BID groups, respectively. At week 6, a significant decrease in ALP was observed with HTD1801 (least square mean; HTD1801 500 mg BID = -53 U/L, P = 0.016; HTD1801 1000 mg BID = -37 U/L, P = 0.019) compared with placebo (98 U/L). ALP reductions were sustained through week 18 in those who remained on therapy, whereas ALP increased in those who crossed over to placebo during period 3. HTD1801 was generally well tolerated; 4 patients experienced serious adverse events, none attributed to HTD1801. DISCUSSION HTD1801 is associated with significant improvement in ALP and warrants further study as a treatment for PSC.
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5
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Hunyady P, Streller L, Rüther DF, Groba SR, Bettinger D, Fitting D, Hamesch K, Marquardt JU, Mücke VT, Finkelmeier F, Sekandarzad A, Wengenmayer T, Bounidane A, Weiss F, Peiffer KH, Schlevogt B, Zeuzem S, Waidmann O, Hollenbach M, Kirstein MM, Kluwe J, Kütting F, Mücke MM. Secondary Sclerosing Cholangitis Following Coronavirus Disease 2019 (COVID-19): A Multicenter Retrospective Study. Clin Infect Dis 2022; 76:e179-e187. [PMID: 35809032 PMCID: PMC9278244 DOI: 10.1093/cid/ciac565] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/27/2022] [Accepted: 07/06/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Secondary sclerosing cholangitis (SSC) is a rare disease with poor prognosis. Cases of SSC have been reported following coronavirus disease 2019 (COVID-SSC). The aim of this study was to compare COVID-SSC to SSC in critically ill patients (SSC-CIP) and to assess factors influencing transplant-free survival. METHODS In this retrospective, multicenter study involving 127 patients with SSC from 9 tertiary care centers in Germany, COVID-SSC was compared to SSC-CIP and logistic regression analyses were performed investigating factors impacting transplant-free survival. RESULTS Twenty-four patients had COVID-SSC, 77 patients SSC-CIP, and 26 patients other forms of SSC. COVID-SSC developed after a median of 91 days following COVID-19 diagnosis. All patients had received extensive intensive care treatment (median days of mechanical ventilation, 48). Patients with COVID-SSC and SSC-CIP were comparable in most of the clinical parameters and transplant-free survival was not different from other forms of SSC (P = .443, log-rank test). In the overall cohort, the use of ursodeoxycholic acid (UDCA) (odds ratio [OR], 0.36 [95% confidence interval {CI}, .16-.80], P = .013; log-rank P < .001) and high serum albumin levels (OR, 0.40 [95% CI, .17-.96], P = .040) were independently associated with an increased transplant-free survival, while the presence of liver cirrhosis (OR, 2.52 [95% CI, 1.01-6.25], P = .047) was associated with worse outcome. Multidrug-resistant organism (MDRO) colonization or infection did not impact patients' survival. CONCLUSIONS COVID-SSC and CIP-SSC share the same clinical phenotype, course of the disease, and risk factors for its development. UDCA may be a promising therapeutic option in SSC, though future prospective trials are needed to confirm our findings.
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Affiliation(s)
- Peter Hunyady
- Alternate Corresponding author, current address Peter Hunyady, Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany. Tel: +49 6301 5122,
| | - Lea Streller
- Clinic for Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Darius F Rüther
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Dominik Bettinger
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Fitting
- Department of Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Jens U Marquardt
- Department of Medicine, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Victoria T Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Asieb Sekandarzad
- Department of Medicine III, Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III, Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ayoub Bounidane
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Felicitas Weiss
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Kai Henrik Peiffer
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | | | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Oliver Waidmann
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Marcus Hollenbach
- Corresponding author, current address: Dr. med. Marcus Maximilian Mücke, Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany. Tel: +49 6301 5122,
| | - Martha M Kirstein
- Department of Medicine, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Johannes Kluwe
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Kütting
- Clinic for Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marcus M Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Gierek M, Merkel K, Ochała-Gierek G, Niemiec P, Szyluk K, Kuśnierz K. Which Suture to Choose in Hepato-Pancreatic-Biliary Surgery? Assessment of the Influence of Pancreatic Juice and Bile on the Resistance of Suturing Materials—In Vitro Research. Biomedicines 2022; 10:biomedicines10051053. [PMID: 35625790 PMCID: PMC9139064 DOI: 10.3390/biomedicines10051053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: The choice of appropriate surgical suture during operation is of great significance. Currently, there are no objective studies regarding the resistance of commonly used sutures in biliary tract surgery. (2) Methods: This fact leads one to conduct research concerning the resistance of the sutures (Polydioxanone, Poliglecaprone, Poliglactin 910, and their analogues coated with antibacterial triclosan) in the environment of sterile and contaminated bile and pancreatic juice. Tensile strength was tested at days 0, 7, 14, 21, and 28 of research. The study was performed in in vitro conditions for 28 days. (3) Results: Pancreatic juice and bile has a significant influence on the tensile strength of each suture. (4) Conclusions: The study indicated that sutures made of polydioxanone had the best qualities during the entire experiment.
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Affiliation(s)
- Marcin Gierek
- Center for Burns Treatment im. Dr Sakiel, ul. Jana Pawła II 2, 41-100 Siemianowice Śląskie, Poland
- Correspondence: (M.G.); (K.M.); Tel.: +48-6-6070-7704 (M.G.); +48-6-9834-2856 (K.M.)
| | - Katarzyna Merkel
- Institute of Materials Engineering, Faculty of Science and Technology, University of Silesia, ul. 75. Pułku Piechoty, 41-500 Chorzów, Poland
- Correspondence: (M.G.); (K.M.); Tel.: +48-6-6070-7704 (M.G.); +48-6-9834-2856 (K.M.)
| | - Gabriela Ochała-Gierek
- Dermatology Department, City Hospital in Sosnowiec, ul. Zegadłowicza 3, 41-200 Sosnowiec, Poland;
| | - Paweł Niemiec
- Department of Biochemistry and Medical Genetics, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
| | - Karol Szyluk
- Department of Physiotherapy, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
- Department of Orthopaedic and Trauma Surgery, District Hospital of Orthopaedics and Trauma Surgery, 41-940 Piekary Śląskie, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, Medical University of Silesia in Katowice, ul. Medyków 14, 40-752 Katowice, Poland;
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7
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[Bacterial hepatobiliary infections : Pathogen spectrum, antimicrobial resistance and current treatment concepts]. Internist (Berl) 2022; 63:349-366. [PMID: 35238985 DOI: 10.1007/s00108-022-01277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/07/2022]
Abstract
Ascending cholangitis and pyogenic liver abscesses are acute febrile bacterial hepatobiliary diseases. Nowadays they frequently occur in patients with structural changes of the biliary system and are usually treated by a combination of interventional drainage procedures and antimicrobial therapy. While Gram-negative Enterobacterales were identified as major causes in the past, biliary tract interventions and antibiotic exposure have contributed to an increase in enterococcal species and extended spectrum beta-lactamase (ESBL)-producing Enterobacterales. When selecting an appropriate empirical treatment the treating internist must consider local and individual risk factors for antimicrobial resistance in addition to pharmacokinetic aspects and disease severity to reduce the likelihood of treatment failure.
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Łuczykowski K, Warmuzińska N, Bojko B. Current approaches to the analysis of bile and the determination of bile acids in various biological matrices as supportive tools to traditional diagnostic testing for liver dysfunction and biliary diseases. Trends Analyt Chem 2021. [DOI: 10.1016/j.trac.2021.116307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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9
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Karasawa Y, Kato J, Kawamura S, Kojima K, Ohki T, Seki M, Tagawa K, Toda N. Risk Factors for Acute Cholangitis Caused by Enterococcus faecalis and Enterococcus faecium. Gut Liver 2021; 15:616-624. [PMID: 33361547 PMCID: PMC8283283 DOI: 10.5009/gnl20214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background/Aims Acute cholangitis (AC) is a potentially life-threatening bacterial infection, and timely antimicrobial treatment, faster than that achieved with bacterial cultures, is recommended. Although the current guidelines refer to empirical antimicrobial treatment, various kinds of antimicrobial agents have been cited because of insufficient analyses on the spectrum of pathogens in AC. Enterococcus spp. is one of the most frequently isolated Gram-positive bacteria from the bile of patients with AC, but its risk factors have not been extensively studied. This study aimed to analyze the risk factors of AC caused by Enterococcusfaecalis and Enterococcusfaecium. Methods Patients with AC who were hospitalized in a Japanese tertiary center between 2010 and 2015 were retrospectively analyzed. Patients’ first AC episodes in the hospital were evaluated. Results A total of 266 patients with AC were identified. E. faecalis and/or E. faecium was isolated in 56 (21%) episodes of AC. Prior endoscopic sphincterotomy (EST), the presence of a biliary stent, prior cholecystectomy, and past intensive care unit admission were more frequently observed in AC patients with E. faecalis and/or E. faecium than in those without such bacteria. Prior EST was identified as an independent risk factor for AC caused by E. faecalis and/or E. faecium in the multivariate analysis. Conclusions Given the intrinsic resistance of E. faecalis and E. faecium to antibiotics, clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with prior EST.
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Affiliation(s)
- Yuki Karasawa
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Jun Kato
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan.,Center of Endoscopy, Mitsui Memorial Hospital, Tokyo, Japan.,Department of Gastroenterology, Chiba University Hospital, Chiba, Japan.,Center of Endoscopy, Chiba University Hospital, Chiba, Japan
| | - Satoshi Kawamura
- Department of Gastroenterology, University of Tokyo Hospital, Tokyo, Japan
| | - Kentaro Kojima
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takamasa Ohki
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Michiharu Seki
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kazumi Tagawa
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Nobuo Toda
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan.,Center of Endoscopy, Mitsui Memorial Hospital, Tokyo, Japan
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Blesl A, Stadlbauer V. The Gut-Liver Axis in Cholestatic Liver Diseases. Nutrients 2021; 13:nu13031018. [PMID: 33801133 PMCID: PMC8004151 DOI: 10.3390/nu13031018] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 12/12/2022] Open
Abstract
The gut-liver axis describes the physiological interplay between the gut and the liver and has important implications for the maintenance of health. Disruptions of this equilibrium are an important factor in the evolution and progression of many liver diseases. The composition of the gut microbiome, the gut barrier, bacterial translocation, and bile acid metabolism are the key features of this cycle. Chronic cholestatic liver diseases include primary sclerosing cholangitis, the generic term secondary sclerosing cholangitis implying the disease secondary sclerosing cholangitis in critically ill patients and primary biliary cirrhosis. Pathophysiology of these diseases is not fully understood but seems to be multifactorial. Knowledge about the alterations of the gut-liver axis influencing the pathogenesis and the outcome of these diseases has considerably increased. Therefore, this review aims to describe the function of the healthy gut-liver axis and to sum up the pathological changes in these cholestatic liver diseases. The review compromises the actual level of knowledge about the gut microbiome (including the mycobiome and the virome), the gut barrier and the consequences of increased gut permeability, the effects of bacterial translocation, and the influence of bile acid composition and pool size in chronic cholestatic liver diseases. Furthermore, therapeutic implications and future scientific objectives are outlined.
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Affiliation(s)
- Andreas Blesl
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
- Correspondence:
| | - Vanessa Stadlbauer
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
- Center for Biomarker Research in Medicine (CBmed), 8010 Graz, Austria
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11
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Jo IH, Kim YJ, Chung WC, Kim J, Kim S, Lim ES, Ahn H, Ryu SY. Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections. Hepatobiliary Pancreat Dis Int 2020; 19:461-466. [PMID: 32535063 DOI: 10.1016/j.hbpd.2020.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. METHODS We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. RESULTS Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029). CONCLUSIONS Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.
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Affiliation(s)
- Ik Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Yeon-Ji Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea.
| | - Woo Chul Chung
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Jaeyoung Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Seonhoo Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Eun Sun Lim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Honggeun Ahn
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Seong Yul Ryu
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
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12
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Blesl A, Jüngst C, Lammert F, Fauler G, Rainer F, Leber B, Feldbacher N, Stromberger S, Wildburger R, Spindelböck W, Fickert P, Horvath A, Stadlbauer V. Secondary Sclerosing Cholangitis in Critically Ill Patients Alters the Gut-Liver Axis: A Case Control Study. Nutrients 2020; 12:E2728. [PMID: 32906634 PMCID: PMC7551864 DOI: 10.3390/nu12092728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Secondary sclerosing cholangitis in critically ill patients (SC-CIP) occurs after long-term intensive care treatment. This study aimed to assess the gut-liver axis in SC-CIP. Stool microbiome composition, gut permeability, bacterial translocation and serum bile acid profiles of 18 SC-CIP patients compared to 11 patients after critical illness without liver disease (CIP controls), 21 patients with cirrhosis and 21 healthy controls were studied. 16S rDNA was isolated from stool and sequenced using the Illumina technique. Diamine oxidase, zonulin, soluble CD14 (sCD14) and lipopolysaccharide binding protein were measured in serum and calprotectin in stool. Serum bile acids were analyzed by high-performance liquid chromatography-mass spectrometry (HPLC-MS). Reduced microbiome alpha diversity and altered beta diversity were seen in SC-CIP, CIP controls and cirrhosis compared to healthy controls. SC-CIP patients showed a shift towards pathogenic taxa and an oralization. SC-CIP, CIP controls and cirrhotic patients presented with impaired gut permeability, and biomarkers of bacterial translocation were increased in SC-CIP and cirrhosis. Total serum bile acids were elevated in SC-CIP and cirrhosis and the bile acid profile was altered in SC-CIP, CIP controls and cirrhosis. In conclusions, observed alterations of the gut-liver axis in SC-CIP cannot solely be attributed to liver disease, but may also be secondary to long-term intensive care treatment.
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Affiliation(s)
- Andreas Blesl
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Christoph Jüngst
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Zürich, 8032 Zürich, Switzerland;
- Department of Medicine II, Saarland University Medical Center, Saarland University, 66421 Homburg, Germany;
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, 66421 Homburg, Germany;
| | - Günter Fauler
- Institute for Medical and Chemical Laboratory Diagnosis, Medical University of Graz, 8036 Graz, Austria;
| | - Florian Rainer
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Bettina Leber
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, 8036 Graz, Austria;
| | - Nicole Feldbacher
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Silvia Stromberger
- AUVA Rehabilitation Clinic Tobelbad, 8144 Tobelbad, Austria; (S.S.); (R.W.)
| | - Renate Wildburger
- AUVA Rehabilitation Clinic Tobelbad, 8144 Tobelbad, Austria; (S.S.); (R.W.)
| | - Walter Spindelböck
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Peter Fickert
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Angela Horvath
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
| | - Vanessa Stadlbauer
- Division for Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (F.R.); (N.F.); (W.S.); (P.F.); (A.H.); (V.S.)
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13
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Kasper P, Tacke F, Steffen HM, Michels G. [Hepatic dysfunction in sepsis]. Med Klin Intensivmed Notfmed 2020; 115:609-619. [PMID: 32725325 DOI: 10.1007/s00063-020-00707-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/27/2020] [Accepted: 05/22/2020] [Indexed: 01/05/2023]
Abstract
Sepsis represents a life-threatening condition that frequently accompanies acute hepatic dysfunction. As a result of systemic inflammation, immune dysregulation, and microcirculatory derangements, different types of liver dysfunction can occur, such as hypoxic hepatitis, sepsis-associated cholestasis, or liver failure. A very serious and late sequela is secondary sclerosing cholangitis of the critically ill patient. Clinical management of sepsis-related liver dysfunction includes the rapid identification and treatment of the suspected underlying infection, hemodynamic stabilization to improve hepatic perfusion, and the optimization of oxygen delivery to the liver. Despite maximum efforts in supportive treatment, the outcome of patients with sepsis or septic shock and concomitant severe hepatic dysfunction remains very poor.
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Affiliation(s)
- Philipp Kasper
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité Campus Mitte und Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Deutschland
| | - Hans-Michael Steffen
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Krankenhaus Eschweiler, Eschweiler, Deutschland
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14
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Kirstein MM, Book T, Manns MP, von Hahn T, Voigtländer T. Secondary sclerosing cholangitis in critically ill patients has a poor outcome but lower tumour incidence than primary sclerosing cholangitis. United European Gastroenterol J 2020; 8:716-724. [PMID: 32366182 PMCID: PMC7437091 DOI: 10.1177/2050640620924274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an emerging disease with grim prognosis. OBJECTIVE Our aim was the analysis of prognostic factors, long-term outcome and risk of tumour development in SSC-CIP compared with primary sclerosing cholangitis (PSC) patients. METHODS Retrospective analysis between 2008 and 2018. RESULTS One hundred and eleven patients with SSC-CIP and 408 PSC patients were identified. Median orthotopic liver transplantation (OLT)-free survival was 16 months for SSC-CIP and 147 months for PSC (p < 0.001). OLT was performed in 18/111 SSC-CIP compared with 166/408 PSC patients (p < 0.001). Malignant tumours were detected in 17.9% of PSC patients (73/408) compared with 2.7% (3/111) in SSC-CIP (p < 0.001). In multivariate Cox regression analysis low levels of C-reactive protein (hazard ratio 4.687 (95% confidence interval (CI) 1.144-19.199, p = 0.032) were significantly associated with a prolonged survival whereas higher age (hazard ratio 0.488 (95% CI 0.23-1.038), p = 0.062) showed a trend for shorter survival in SSC-CIP. For PSC malignancies (hazard ratio 0.42 (95% CI 0.313-0.575), p < 0.001) and higher age (hazard ratio 0.709 (95% CI 0.544-0.922), p = 0.01) were associated with a shorter OLT-free survival. CONCLUSION SSC-CIP is characterized by acute onset of liver disease and poor prognosis but with lower tumour incidence compared with PSC.
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Affiliation(s)
- Martha M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Thorsten Book
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Thomas von Hahn
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Torsten Voigtländer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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15
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Bachta KER, Allen JP, Cheung BH, Chiu CH, Hauser AR. Systemic infection facilitates transmission of Pseudomonas aeruginosa in mice. Nat Commun 2020; 11:543. [PMID: 31992714 PMCID: PMC6987207 DOI: 10.1038/s41467-020-14363-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/18/2019] [Indexed: 01/08/2023] Open
Abstract
Health care-associated infections such as Pseudomonas aeruginosa bacteremia pose a major clinical risk for hospitalized patients. However, these systemic infections are presumed to be a "dead-end" for P. aeruginosa and to have no impact on transmission. Here, we use a mouse infection model to show that P. aeruginosa can spread from the bloodstream to the gallbladder, where it replicates to extremely high numbers. Bacteria in the gallbladder can then seed the intestines and feces, leading to transmission to uninfected cage-mate mice. Our work shows that the gallbladder is crucial for spread of P. aeruginosa from the bloodstream to the feces during bacteremia, a process that promotes transmission in this experimental system. Further research is needed to test to what extent these findings are relevant to infections in patients.
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Affiliation(s)
- Kelly E R Bachta
- Department of Microbiology-Immunology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Jonathan P Allen
- Department of Microbiology-Immunology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Department of Microbiology and Immunology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Bettina H Cheung
- Department of Microbiology-Immunology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alan R Hauser
- Department of Microbiology-Immunology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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16
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Martins P, Verdelho Machado M. Secondary Sclerosing Cholangitis in Critically Ill Patients: An Underdiagnosed Entity. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 27:103-114. [PMID: 32266307 DOI: 10.1159/000501405] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a recently identified cholestatic liver disease occurring in patients without prior history of hepatobiliary disease, after receiving treatment in the intensive care unit (ICU) in different settings, including cardiothoracic surgery, infection, trauma, and burns. It is a rare entity, being estimated to occur in 1/2,000 patients in an ICU; however, it is a dismal condition, with up to half of the patients dying during the ICU stay and with rapid progression to liver cirrhosis over weeks to months. SSC-CIP should be considered in the differential diagnosis of cholestasis in the ICU, particularly when cholestasis persists after recovery from the critical event. Diagnosis is established with magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography showing dilations and stenoses of the intrahepatic bile ducts as well as biliary casts. No available treatment has been shown to slow the rapid progression of the disease, and liver transplant referral should be considered early after the diagnosis of SSC-CIP. Increased awareness and timely diagnosis are crucial in order to improve the current appalling outcome.
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Affiliation(s)
- Pedro Martins
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mariana Verdelho Machado
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Serviço de Gastrenterologia, Hospital de Santa Maria, CHULN, Lisbon, Portugal
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17
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Microbial Profiles and Risk Factors of Preexisting Biliary Infection in Patients with Therapeutic Endoscopy. Gastroenterol Res Pract 2019; 2019:1527328. [PMID: 31191641 PMCID: PMC6525931 DOI: 10.1155/2019/1527328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/26/2019] [Indexed: 12/16/2022] Open
Abstract
Background The bile infection may already exist before the administration of an interventional procedure, despite no clinical manifestations of cholangitis detected. Blood cultures remained negative even in more than half of the febrile cases with cholangitis. Risk factors associated with bacterial growth in bile before the intervention are not well defined. To establish the bacterial profiles isolated from the bile samples and to identify risk factors for bacterial colonization in the bile system. Methods Individuals who underwent endoscopic retrograde cholangiopancreatography (ERCP) interventions were enrolled. Bile samples were aspirated and were immediately transferred into a sterile tube for storage. Results Positive bile cultures were detected in 363 (38.0%) of 956 patients, including 322 benign diseases and 41 malignances. Of 363 positive cases, 351 (96.7%) were monoinfection and 12 (3.3%) multi-infection. Escherichia coli were the most common Gram-negative bacteria (210, 56.0%), followed by Klebsiella pneumoniae (45, 12.0%). Enterococcus faecalis represented the most common Gram-positive microorganism (19, 5.07%), while Candida albicans (11, 2.93%) were the dominant fungi. Klebsiella pneumoniae were more frequently detected in malignant diseases (P = 0.046). Age, previous ERCP history or OLT history, and CBD diameter were independent risk factors for positive cultures (P < 0.05) while preoperative jaundice drug therapy was the protective factor for bile infection (P < 0.05). Conclusion Monomicrobial infection was dominant among all infections, and Klebsiella pneumoniae strains were more frequently isolated from patients with malignant diseases. To effectively manage patients who are at a high risk for bile infection, a detailed diagnosis and treatment plan for each case should be prepared.
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18
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Siebers C, Kinzinger J, Hinske LC, Bauer A, Scheiermann P, Zoller M, Guba M, Angele M, Pratschke S, Weig T. Effect of Intraoperative Single-Shot Application of Vancomycin in Liver Transplant Recipients on Postoperative Infections With Enterococcus faecium and Enterococcus faecalis. EXP CLIN TRANSPLANT 2018; 16:701-707. [PMID: 29676703 DOI: 10.6002/ect.2017.0153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Infections are major causes of morbidity and mortality in the early postoperative period after liver transplant. We observed a high rate of enterococcal infections at our center. Therefore, we added an intraoperative single shot of vancomycin to the standard regimen of meropenem given over 5 days. The aim of this study was to determine the prevalence of both Enterococcus faecium and Enterococcus faecalis infections during the first 28 days after surgery depending on the type of antibiotic prophylaxis and their implications on mortality and morbidity. MATERIALS AND METHODS Our retrospective cohort analysis included 179 patients: 93 patients received meropenem only and 86 patients were treated with meropenem plus vancomycin. RESULTS During the first 28 days after transplant, microbiological tests showed that 51 patients (28.5%) were positive for Enterococcus faecium and 25 patients (14.0%) were positive for Enterococcus faecalis. Enterococcus faecium infections appeared significantly more often in patients without vancomycin (P = .013). In the second week after transplant, there was a significant reduction in Enterococcus faecium infections in the meropenem plus vancomycin group (P = .015). Enterococcus faecalis infections occurred more often in the patients receiving meropenem alone, but results were not statistically significant (P = .194). There was a trend toward more frequent renal replacement therapy in the meropenem plus vancomycin group. We found no differences between the groups regarding survival after 1 and 2 years, length of hospital stay, or duration in the intensive care unit. Overall 1-year survival was 78.8% (141/179 patients). CONCLUSIONS Although postoperative Enterococcus species infections can be reduced after liver transplant by adding vancomycin to the intraoperative antibiotic regimen, it does not improve the long-term outcomes.
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Affiliation(s)
- Christian Siebers
- From the Department of Anaesthesiology, Ludwig-Maximilians University, Ludwig-Maximilians University, Munich, Germany
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Mohammad Alizadeh AH. Cholangitis: Diagnosis, Treatment and Prognosis. J Clin Transl Hepatol 2017; 5:404-413. [PMID: 29226107 PMCID: PMC5719198 DOI: 10.14218/jcth.2017.00028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/23/2017] [Accepted: 07/12/2017] [Indexed: 12/12/2022] Open
Abstract
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.
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20
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NOD2 gene variants confer risk for secondary sclerosing cholangitis in critically ill patients. Sci Rep 2017; 7:7026. [PMID: 28765628 PMCID: PMC5539147 DOI: 10.1038/s41598-017-06268-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/08/2017] [Indexed: 12/27/2022] Open
Abstract
Sclerosing cholangitis in critically ill patients (SC-CIP) is a progressive cholestatic disease of unknown aetiology characterized by chronic biliary infections. Hence we hypothesized that common NOD2 (nucleotide-binding oligomerisation domain containing 2) gene variants, known risk factors for Crohn's disease and bacterial translocation in liver cirrhosis, increase the odds of developing SC-CIP. Screening of 4,641 endoscopic retrograde cholangiography procedures identified 17 patients with SC-CIP, who were then genotyped for the three common NOD2 mutations (Cohort 1, discovery cohort). To validate the association, we subsequently tested these NOD2 variants in 29 patients from SC-CIP cohorts of three additional medical centers (Cohort 2, replication cohort). In Cohort 1, the NOD2 variants were present in 5 of 17 SC-CIP patients (29.4%), which is twice the frequency of the general population. These results were replicated in Cohort 2 with 8 patients (27.6%) showing NOD2 mutations. In contrast, polymorphisms of hepatocanalicular transporter genes did not have major impact on SC-CIP risk. This first study on genetic susceptibility in SC-CIP patients shows an extraordinary high frequency of NOD2 variation, pointing to a critical role of inherited impaired anti-bacterial defense in the development of this devastating biliary disease.
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21
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Wobser H, Gunesch A, Klebl F. Prophylaxis of post-ERC infectious complications in patients with biliary obstruction by adding antimicrobial agents into ERC contrast media- a single center retrospective study. BMC Gastroenterol 2017; 17:10. [PMID: 28086796 PMCID: PMC5237205 DOI: 10.1186/s12876-017-0570-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 01/07/2017] [Indexed: 02/03/2023] Open
Abstract
Background Patients with biliary obstruction are at high risk to develop septic complications after endoscopic retrograde cholangiography (ERC). We evaluated the benefits of local application of antimicrobial agents into ERC contrast media in preventing post-ERC infectious complications in a high-risk study population. Methods Patients undergoing ERC at our tertiary referral center were retrospectively included. Addition of vancomycin, gentamicin and fluconazol into ERC contrast media was evaluated in a case-control design. Outcomes comprised infectious complications within 3 days after ERC. Results In total, 84 ERC cases were analyzed. Primarily indications for ERC were sclerosing cholangitis (75%) and malignant stenosis (9.5%). Microbial testing of collected bile fluid in the treatment group was positive in 91.4%. Detected organisms were sensitive to the administered antimicrobials in 93%. The use of antimicrobials in contrast media was associated with a significant decrease in post-ERC infectious complications compared to non-use (14.3% vs. 33.3%; odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.114–0.978). After adjusting for the variables acute cholangitis prior to ERC and incomplete biliary drainage, the beneficial effect of intraductal antibiotic prophylaxis was even more evident (OR = 0.153; 95% CI: 0.039–0.598, p = 0.007). Patients profiting most obviously from intraductal antimicrobials were those with secondary sclerosing cholangitis. Conclusion Local application of a combination of antibiotic and antimycotic agents to ERC contrast media efficiently reduced post-ERC infectious events in patients with biliary obstruction. This is the first study that evaluates ERC-related infectious complications in patients with secondary sclerosing cholangitis. Our first clinical results should now be prospectively evaluated in a larger patient cohort to improve the safety of ERC, especially in patients with secondary sclerosing cholangitis.
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Affiliation(s)
- Hella Wobser
- Department of Internal Medicine and Gastroenterology, University Hospital of Regensburg, Regensburg, 93042, Germany.
| | - Agnetha Gunesch
- Department of Internal Medicine and Gastroenterology, University Hospital of Regensburg, Regensburg, 93042, Germany
| | - Frank Klebl
- Department of Internal Medicine and Gastroenterology, University Hospital of Regensburg, Regensburg, 93042, Germany.,Present address: Praxiszentrum Alte Mälzerei, Regensburg, Germany
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Reuken PA, Torres D, Baier M, Löffler B, Lübbert C, Lippmann N, Stallmach A, Bruns T. Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis. PLoS One 2017; 12:e0169900. [PMID: 28076388 PMCID: PMC5226732 DOI: 10.1371/journal.pone.0169900] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Acute cholangitis (AC) requires the immediate initiation of antibiotic therapy in addition to treatment for biliary obstruction. Against a background of an increasing prevalence of multi-drug resistant (MDR) bacteria, the risk factors for the failure of empiric therapy must be defined. Methods Using a pathogen-based approach, 1764 isolates from positive bile duct cultures were retrospectively analyzed to characterize the respective pathogen spectra in two German tertiary centers. Using a patient-based approach, the clinical and laboratory data for 83 patients with AC were assessed to identify risk factors for AC with pathogens resistant to the applied empiric therapy. Results Bile cultures were predominantly polymicrobial, and empiric antibiotic therapies did not cover the full biliary pathogen spectrum in 78% of cases. MDR bacteria were isolated from the bile of 24/83 (29%) patients. The univariate risk factors for biliary MDR bacteria were male sex, nosocomial AC, prior antibiotic exposure and prior biliary stenting, of which biliary stenting was the only independent risk factor according to multivariate analysis (OR = 3.8; 95% CI 1.3–11.0, P = 0.013). Although there were no significant differences in survival or hospital stay in AC patients with and without detected biliary MDR pathogens, the former more often had a concomitant bloodstream infection (58% vs. 24%; P = 0.019), including those involving MDR pathogens or fungi (21% vs. 2%; P = 0.007). Conclusion Patients with biliary stents who develop AC should receive empiric therapy covering enterococci and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. These patients are at an increased risk for bloodstream infections by MDR pathogens or fungi.
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Affiliation(s)
- Philipp A. Reuken
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
- * E-mail:
| | - Dorian Torres
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Michael Baier
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Bettina Löffler
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Christoph Lübbert
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Norman Lippmann
- Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Tony Bruns
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
- The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
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Reuken PA, Torres D, Baier M, Löffler B, Lübbert C, Lippmann N, Stallmach A, Bruns T. Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis. PLoS One 2017. [PMID: 28076388 DOI: 10.137/journal.pone.0169900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute cholangitis (AC) requires the immediate initiation of antibiotic therapy in addition to treatment for biliary obstruction. Against a background of an increasing prevalence of multi-drug resistant (MDR) bacteria, the risk factors for the failure of empiric therapy must be defined. METHODS Using a pathogen-based approach, 1764 isolates from positive bile duct cultures were retrospectively analyzed to characterize the respective pathogen spectra in two German tertiary centers. Using a patient-based approach, the clinical and laboratory data for 83 patients with AC were assessed to identify risk factors for AC with pathogens resistant to the applied empiric therapy. RESULTS Bile cultures were predominantly polymicrobial, and empiric antibiotic therapies did not cover the full biliary pathogen spectrum in 78% of cases. MDR bacteria were isolated from the bile of 24/83 (29%) patients. The univariate risk factors for biliary MDR bacteria were male sex, nosocomial AC, prior antibiotic exposure and prior biliary stenting, of which biliary stenting was the only independent risk factor according to multivariate analysis (OR = 3.8; 95% CI 1.3-11.0, P = 0.013). Although there were no significant differences in survival or hospital stay in AC patients with and without detected biliary MDR pathogens, the former more often had a concomitant bloodstream infection (58% vs. 24%; P = 0.019), including those involving MDR pathogens or fungi (21% vs. 2%; P = 0.007). CONCLUSION Patients with biliary stents who develop AC should receive empiric therapy covering enterococci and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. These patients are at an increased risk for bloodstream infections by MDR pathogens or fungi.
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Affiliation(s)
- Philipp A Reuken
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Dorian Torres
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Michael Baier
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Bettina Löffler
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Leipzig, Germany
| | - Christoph Lübbert
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Norman Lippmann
- Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany.,The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Tony Bruns
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany.,The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
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Abstract
Sepsis and septic shock are characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The liver has a central role during sepsis, and is essential to the regulation of immune defence during systemic infections by mechanisms such as bacterial clearance, acute-phase protein or cytokine production and metabolic adaptation to inflammation. However, the liver is also a target for sepsis-related injury, including hypoxic hepatitis due to ischaemia and shock, cholestasis due to altered bile metabolism, hepatocellular injury due to drug toxicity or overwhelming inflammation, as well as distinct pathologies such as secondary sclerosing cholangitis in critically ill patients. Hence, hepatic dysfunction substantially impairs the prognosis of sepsis and serves as a powerful independent predictor of mortality in the intensive care unit. Sepsis is particularly problematic in patients with liver cirrhosis (who experience increased bacterial translocation from the gut and impaired microbial defence) as it can trigger acute-on-chronic liver failure - a syndrome with high short-term mortality. Here, we review the importance of the liver as a guardian, modifier and target of sepsis, the factors that contribute to sepsis in patients with liver cirrhosis and new therapeutic strategies.
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Voigtländer T, Jaeckel E, Lehner F, Manns MP, Lankisch TO. Liver transplantation for critically Ill patients with secondary sclerosing cholangitis: Outcome and complications. Liver Transpl 2015; 21:1295-9. [PMID: 26069199 DOI: 10.1002/lt.24192] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/22/2015] [Accepted: 05/27/2015] [Indexed: 12/13/2022]
Abstract
Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a destructive cholangiopathy with a poor prognosis. Liver transplantation (LT) is an established therapeutic option in end-stage liver disease but is insufficiently evaluated in patients with SSC-CIP. Our aim was the retrospective analysis of the outcome and complications of patients with SSC-CIP undergoing LT between 2002 and 2012. Demographic characteristics, laboratory, transplantation, and follow-up data were compared to sex- and age-matched patients undergoing LT because of other reasons. Quality of life (QoL) before and after LT was assessed in a retrospective telephone interview. LT was performed in 21 patients with SSC-CIP. The main causes for intensive care unit admission comprised cardiothoracic surgery interventions (10/21, 48%), polytrauma (6/21, 29%), and pneumonia (3/21, 14%). Median follow-up period after LT was 82 months (interquartile range [IQR], 37-129) for patients with SSC-CIP and 83 months (IQR, 55-104) for control patients. Biopsy-proven rejection episodes in patients with SSC-CIP (4/21, 19%) were similar compared to control patients (12/60, 20%; P = 0.93). Cytomegalovirus infections were equal in both groups (10/21, 48% versus 25/60, 42%; P = 0.64). The 1-, 3-, and 5-year survival rates of patients with SSC-CIP versus control patients were 100% versus 98%, 86% versus 92%, and 76% versus 87%, respectively (P > 0.05). The QoL improved significantly after LT in SSC-CIP. In conclusion, LT is a valid option for patients with SSC-CIP with excellent long-term outcome and improvement of QoL.
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Affiliation(s)
- Torsten Voigtländer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tim O Lankisch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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