Acute (ascending) cholangitis

Biliary Endoscopic Retrograde Cholangiopancreatography

Since inception in 1968, biliary endoscopic retrograde cholangiopancreatography (ERCP) has transformed into a highly effective, minimally invasive modality for the identification and treatment of a variety of biliary pathologies including benign, malignant, and iatrogenic diseases. The diagnostic role of ERCP has been largely replaced by high-quality imaging modalities including endoscopic ultrasound and magnetic resonance cholangiopancreatography. However, there continues to be significant demand for therapeutic procedures. This article reviews the general principles of ERCP, as well as common indications, contraindications, and potential adverse events with which endoscopists and referring physicians should be familiar.

Acute cholangitis: a state-of-the-art review

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Proteomic analysis of serum extracellular vesicles from biliary tract infection patients to identify novel biomarkers

Biliary tract infection (BTI), a commonly occurring abdominal disease, despite being extensively studied for its initiation and underlying mechanisms, continues to pose a challenge in the quest for identifying specific diagnostic biomarkers. Extracellular vesicles (EVs), which emanate from diverse cell types, serve as minute biological entities that mirror unique physiological or pathological conditions. Despite their potential, there has been a relatively restricted exploration of EV-oriented methodologies for diagnosing BTI. To uncover potent protein biomarkers for BTI patients, we applied a label-free quantitative proteomic method known for its unbiased and high-throughput nature. Furthermore, 192 differentially expressed proteins surfaced within EVs isolated from individuals afflicted with BTI. Subsequent GO and KEGG analyses pinpointed Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) and Crumbs homolog 3 (CRB3) as noteworthy biomarkers. Validation via data analysis of plasma-derived EV samples confirmed their specificity to BTI. Our study leveraged an unbiased proteomic tool to unveil CEACAM1 and CRB3 as promising protein biomarkers in serum EVs, presenting potential avenues for the advancement of diagnostic systems for BTI detection.

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

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

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

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.

A Multipathogen Bile Sample-based PCR Assay Can Guide Empirical Antimicrobial Strategies in Cholestatic Liver Diseases

BACKGROUND AND OBJECTIVES

Polymerase chain reaction (PCR) techniques provide rapid detection of pathogens. This pilot study evaluated the diagnostic utility and clinical impact of multiplex real-time PCR (mRT-PCR, SeptiFast) vs. conventional microbial culture (CMC) in bile samples of patients with chronic cholestatic liver diseases (cCLDs), endoscopic retrograde cholangio-pancreatography (ERCP), and peri-interventional-antimicrobial-prophylaxis (pAP).

METHODS

We prospectively collected bile samples from 26 patients for microbiological analysis by CMC and mRT-PCR. Concordance of the results of both methods was determined by Krippendorff's alpha (α) for inter-rater reliability and the Jaccard index of similarity.

RESULTS

mRT-PCR_bile and CMC_bile results were concordant for only Candida albicans (α=0.8406; Jaccard index=0.8181). mRT-PCR_bile detected pathogens in 8/8 cases (100%), CMC_bile in 7/8 (87.5%), and CMC_blood in 5/8 (62.5%) with clinical signs of infection. mRT-PCR_bile, CMC_bile, and CMC_blood had identical detection results in 3/8 (37.5%) with clinical signs of infection (two Klebsiella spp. and one Enterococcus faecium). The total pathogen count was significantly higher with mRT-PCR_bile than with CMC_bile (62 vs. 31; χ²=30.031, p<0.001). However, pathogens detected by mRT-PCR_bile were more often susceptible to pAP according to the patient infection/colonization history (PI/CH) and surveillance data for antibiotic resistance in our clinic (DARC). Pathogens identified by mRT-PCR_bile and resistant to pAP by PI/CH and DARC were likely to be clinically relevant.

CONCLUSIONS

mRT-PCR in conjunction with CMCs for bile analysis increased diagnostic sensitivity and may benefit infection management in patients with cholestatic diseases. Implementation of mRT-PCR in a bile sample-based diagnostic routine can support more rapid and targeted use of antimicrobial agents in cCLD-patients undergoing ERCP and reduce the rate/length of unnecessary administration of broad-spectrum antibiotics.

Hepatobiliary scintigraphy in the assessment of bile outflow in patients with biliodigestive anastomosis

Aim. To determine the character of bile outflow in patients who underwent biliary tract reconstructive surgery without any clinical and instrumental evidence of the stricture of biliodigestive anastomosis.

Materials and methods. The authors analyzed the findings of radionuclide biliary tract studies conducted in 102 patients with biliodigestive anastomosis from 2016 to 2020. The significant relationship between clinical data and hepatobiliary scintigraphy results was confirmed using Fisher’s exact test.

Results. In 75 patients (73.5%), bile outflow disturbance was attributed to the efferent loop motility. Of these cases, 3 (4%) involved paresis of the efferent loop, while 70 (93.3%) exhibited multiple episodes of reflux from the efferent loop into the biliodigestive anastomosis and the intrahepatic bile ducts. In 2 patients (2.6%) showing no clinical signs of chronic cholangitis, a rare reflux from the efferent loop into the biliodigestive anastomosis and the intrahepatic bile ducts was noted.

Conclusions. Efferent loop dysfunction can greatly disturb bile outflow following the formation of a biliodigestive anastomosis, thus creating conditions for the development of complications.

Biliary Tract Instrumentations Prior to Elective Cholecystectomy: Effect on Biliary Microbiome

Background: Calculus biliary disease is a common condition that requires invasive procedures in complicated cases. The effect of biliary instrumentation on the biliary microbiome and its impact on surgical complications after elective cholecystectomy remains unclear. This study aimed to assess the impact of prior biliary instrumentation on the biliary microbiome, as well as on the clinical outcomes of cholecystectomy. Patients and Methods: This retrospective study included all patients who underwent elective cholecystectomy for calculus biliary disease between 2015 and 2020 in a single medical center. Data regarding biliary instrumentation prior to cholecystectomy, biliary cultures obtained during cholecystectomy, and clinical outcomes were collected. A comparison between patients with and without prior instrumentation was performed with regard to biliary cultures and clinical outcomes. Results: Of the 508 patients studied, 109 patients underwent biliary instrumentation prior to cholecystectomy. Patients with prior instrumentation were older and more likely to be men (p < 0.0001). Prior instrumentation was also associated with higher rates of conversion to open surgery (p < 0.0001). Positive biliary cultures and polymicrobial growth were both more common among patients with prior instrumentation (p < 0.0001). Prior instrumentation was associated with longer length of hospital stay, as well as higher rates of perioperative complications and surgical site infection (p < 0.0001). Conclusions: Prior instrumentation was associated with poorer clinical outcomes and affected the biliary microbiome. The different results of biliary cultures in these patients may suggest that an alternative empiric antibiotic regimen should be considered when treating patients with biliary instrumentation.

Effect of Antibiotic Resistance of Pathogens on Initial Antibiotic Therapy for Patients With Cholangitis

Objectives

Considering that pathogens resistant to initial antibiotic therapies for cholangitis can affect mortality rates, appropriate initial empiric antibiotic therapy is important. However, evidence regarding the influence of pathogens resistant to initial antibiotics in patients with cholangitis who have undergone early endoscopic retrograde cholangiopancreatography (ERCP) is limited, and the conditions in several cases can improve with early ERCP even when pathogens resistant to initial antibiotics are detected on time. Therefore, this study aimed to assess the influence of pathogens resistant to initial antibiotics on the course of cholangitis in patients undergoing early ERCP.

Materials and methods

Patients (n=266) with positive blood or bile culture results treated with early ERCP were divided into those with cultures that were resistant to the initial antibiotics (antibiotic-resistant group; n=66; 24.8%) and those with cultures that were sensitive to the initial antibiotics (antibiotic-sensitive group; n=200; 75.2%). The duration of hospitalization, in-hospital mortality rates due to cholangitis, rates of increased disease severity, and complications during hospitalization were studied.

Results

Enterococcus, Enterobacter, Citrobacter, and Pseudomonas species showed high resistance to several antibiotics. No significant between-group differences were found in the duration of hospitalization, in-hospital mortality rates due to cholangitis, and rates of increased disease severity. However, the rate of post-ERCP cholecystitis was significantly higher in the antibiotic-resistant group than in the antibiotic-sensitive group (p=0.0245).

Conclusions

Even if the initial antibiotics were ineffective, the rate of fatal outcomes did not increase among patients with cholangitis who had undergone early ERCP. However, when initial antibiotics were ineffective, the frequency of post-ERCP cholecystitis increased even after early bile duct decompression.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Cholangio-venous reflux of biliary contents through paracellular pathways between hepatocytes in patients with acute cholangitis

BACKGROUND

We re-analyzed data on cholangio-venous reflux from a clinical study conducted prospectively on 22 patients in 1974.

METHOD

Direct cholangiography was performed with indocyanine green (ICG) mixed into UrographinR under monitoring of intrabiliary pressure, and the participants were allocated to three groups according to whether ICG leakage into the blood, signs of infection, or both, were present.

RESULTS

The intrabiliary pressure of six patients negative for both ICG leakage and signs of infection was approximately 19.5 (median, [range 18-22]) cmH2 O. In contrast, for the five patients positive for ICG leakage but negative for signs of infection, the intrabiliary pressure was higher (median 32.0 [range 27-41) cmH2 O]. The 11 patients positive for both ICG leakage and signs of infection had the highest intrabiliary pressure (median 48.0 [range 33-77] cmH2 O). Our analyses revealed that, as the intrabiliary pressure increased, the status of ICG leakage and signs of infection appeared in a stepwise fashion.

CONCLUSION

Our findings suggest that the tight junctions sealing the bile canaliculi deteriorated with increasing intrabiliary pressure, resulting in reflux of the biliary contents into the vascular system via paracellular pathways between hepatocytes.

Antibiotics for adults with acute cholecystitis or acute cholangitis or both

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of antibiotics treatment versus placebo, no intervention, or another antibiotic for people with cholecystitis or cholangitis, or both.

Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

BACKGROUND

Cholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria.

RESULTS

28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %-13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33-3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00-648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64-463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %-11%) after a median time interval of 12 months. The quality of the included studies was low to moderate.

CONCLUSION

Cholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.

Gallstones at chronic spontaneous urticaria patients: A retrospective clinical study

Chronic spontaneous urticaria (CSU) is a chronic, inflammatory skin disease can be triggered by many factors such as inflammatory process. To assess accompanying gallstone in CSU patients and to evaluate laboratory test results. We retrospectivelyscanned the files of the 108 patients with CSU who had been diagnosed CSU in September 2017-September 2019. Accompanied gallstone cases by detecting transabdominal ultrasound (TUS) or were 11 patients. Nine patients had also had cholecystectomy history. We seperated these 20 patients as Group A than the rest. WBC count is 9.38 ± 2.37 in Group A and 8.03 ± 2.04 in Group B. Platelet count was also differ between two groups significantly (Group A = 328.70 ± 85.62 × 10³ /mm³ vs. Group B = 287.12 ± 72.77 × 10³ /mm³ ). Neutrophil count was more in Group A (5.87 ± 1.65) than Group B (4.76 ± 1.75). Gallstone history of family was significantly higher in Group A (n = 12 positive/8 negative) than Group B. These findings were significant statistically p < .05. CSU can be associated with inflammation and gallstones. It is needed to perform further investigations to detect these relations and pathways.

Increasing burden of biliary tract infection caused by extended-spectrum beta-lactamase-producing organisms in Korea: A nationwide population-based study

BACKGROUND AND AIM

Biliary tract infections (BTIs) are a major cause of bacteremia. The prevalence of antibiotic-resistant pathogens in BTI patients is reported to be increasing. We used a nationwide database to evaluate the prevalence of, and risk factors for, BTIs caused by extended-spectrum beta-lactamase-producing organisms (ESBL-PO) in Korea.

METHODS

Patients with a BTI diagnosis, an admission history, a history of a BTI-related procedure, and antibiotic use for ≥ 4 days between 2007 and 2016 were identified from the Health Insurance Review and Assessment Service database. A BTI treated with carbapenems (BTI-TC) was used as the surrogate for a BTI caused by ESBL-PO. We conducted a multivariate logistic regression analysis to determine the risk factors for BTI-TC.

RESULTS

In total, 341 002 patients were enrolled. The overall percentage of BTI-TC among BTIs was 2.4%, with an increasing annual trend (P < 0.0001). The risk of acute cholangitis caused by ESBL-PO increased significantly in men, older patients, patients with comorbidities, patients with a history of a biliary procedure within the previous year, and patients with a history of antibiotic use within the previous 90 days. Regarding antibiotic use, the patients at highest risk were those previously prescribed carbapenems (adjusted odds ratio, 4.77; P < 0.0001).

CONCLUSIONS

The prevalence of BTIs caused by ESBL-PO has increased during the last 10 years. Initial carbapenem therapy should be considered for elderly patients with acute cholangitis if they have had a previous biliary procedure and/or a history of carbapenem administration within the previous 90 days.

Does measurement of the hepatic artery velocity improve the sonographic diagnosis of cholangitis?

OBJECTIVE

To determine the frequency of elevated peak systolic proper hepatic artery velocity (HAV) in patients with acute cholangitis and to determine the diagnostic performance of this metric relative to existing criteria.

METHODS

Between 9/2016 and 11/2017, 107 patients clinically suspected to have cholangitis were referred for an abdominal ultrasound. Of these, 56 patients had HAV measurements and were included in the final analysis. Clinical and imaging features, including HAV, HAV resistive index (RI), portal vein velocity (PVV), biliary dilation, and presence of an obstructive etiology were extracted. The diagnostic performance of HAV was compared to the existing available clinical criteria (Charcot's triad and 2018 Tokyo Guidelines). Elevated HAV was defined as HAV > 100 cm/s. Presence of cholangitis was determined by the discharge summary following medical workup and admission or observation.

RESULTS

32% had cholangitis while 68% did not. Average HAV for patients with cholangitis was 152 ± 54 cm/s versus 91 ± 44 cm/s for those without (p < 0.0001; t test). The HAV was elevated in 83% of patients with cholangitis. When considered in isolation, an elevated HAV had a high negative predictive value (90%), was more accurate (77%; 95% confidence interval 64-87%) than Charcot's triad (73%; 60-83%), and had similar accuracy compared to 2018 Tokyo Guidelines (79%; 66-88%). Substitution of conventional imaging criteria with elevated HAV in the 2018 Tokyo Guidelines yielded the highest overall accuracy of 84% (72-92%).

CONCLUSION

HAV is elevated in the majority of patients with cholangitis. Substitution of an elevated HAV for conventional sonographic criteria is more accurate than existing clinical criteria in identifying patients with cholangitis.

Infections of the Hepatobiliary System

Hepatobiliary infections account for a small but clinically important proportion of emergency department presentations. They present a clinical challenge due to the broad range of imaging characteristics on presentation. Recognition of complications is imperative to drive appropriate patient care and resource utilization to avoid diagnostic pitfalls and avert adverse patient outcomes. A thorough understanding of anatomy infectious pathology of hepatobiliary system is essential in the emergency setting to confidently diagnose and guide medical intervention. Many presentations of hepatobiliary infection have characteristic imaging features on individual imaging modalities with others requiring the assimilation of findings of multiple imaging modalities along with incorporating the clinical context and multispecialist consultation. Familiarity with the strengths of individual imaging modalities in the radiologists' arsenal is imperative to guide the appropriate utilization of resources, particularly in the emergent time sensitive setting. Accurate identification and diagnosis of hepatobiliary infections is vital for appropriate patient care and management stratification.

Duct-To-Duct Biliary Anastomosis with Removable Internal Biliary Stent During Major Hepatectomy Extended to the Biliary Confluence

BACKGROUND

Roux-en-Y hepaticojejunostomy (HJ) currently represents the gold standard after resection of the biliary confluence. This non-physiological reconstruction poses several problems such as repeated cholangitis or stricture without conventional endoscopic access. Our aim was to describe and to report both feasibility and results of duct-to-duct anastomosis with removable internal biliary drain (RIBS) as an alternative technique to the HJ after resection of the biliary confluence in patients undergoing major liver resection.

METHODS

Between January 2014 and January 2018, all patients who underwent a major hepatectomy associated with resection of the biliary confluence and reconstruction by duct-to-duct biliary anastomosis with RIBS were retrospectively included. Patient demographics, tumor characteristics, pre- and postoperative outcomes, early and late biliary complications, endoscopic complications, and clinical follow-up were collected.

RESULTS

Twelve patients were included. The operative time was 326 ± 45 min (range 240-380 min). There was no postoperative mortality. Only one patient experienced biliary anastomotic leakage treated exclusively by radiological and endoscopic drainage. Four patients had an asymptomatic stricture of the biliary anastomosis detected by endoscopic retrograde cholangiopancreatography (ERCP) during the extraction of the RIBS requiring iterative dilatation and replacement of the RIBS. Among 21 performed ERCP, no complications such as failure of RIBS extraction, duodenal perforation, bleeding after sphincterotomy, cholangitis, or pancreatitis were observed. After a mean and a median follow-up of respectively 15.0 ± 14.9 and 8.7 months (range 2.0-46.1 months), no cholangitis occurred.

CONCLUSION

Duct-to-duct biliary anastomosis with RIBS insertion after resection of the biliary confluence represents a feasible and safe alternative to the HJ.

Post-ERCP biliary complications in patients with biliary type sphincter of Oddi dysfunction

Sphincter of Oddi dysfunction (SOD) has a high risk of post-ERCP pancreatitis. Cholangitis, colicky pain, and jaundice from cholestasis also occur after ERCP. However, these post-ERCP biliary complications have not been sufficiently evaluated in SOD. Thus, the risk factors and post-ERCP biliary complications in biliary-type SOD were evaluated. From December 1996 to January 2017, 72 patients with suspected biliary-type SOD were selected, and 60 patients who underwent ERCP were included in this study. The incidence of biliary complications compared to control group and factors associated with post-ERCP cholangitis were investigated. More frequent biliary complications, including biliary pain and abnormal liver function, occurred in SOD group than in control group, especially in type I SOD patients. Post-ERCP cholangitis occurred significantly more often with bile duct diameter ≥12 mm (26%, 5/19) than with bile duct diameter <11 mm (2.4%, 1/41; p = 0.016). Age ≥75 years was also a risk factor for post-ERCP cholangitis (p = 0.013). Multivariate analysis confirmed that bile duct diameter ≥12 mm was a significant risk factor for post-ERCP cholangitis. Post-ERCP biliary complications occurred frequently in biliary-type SOD, especially type I. Biliary diameter ≥12 mm was an important risk factor for post-ERCP cholangitis.

Risk factor analysis of post-ERCP cholangitis: A single-center experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may have complications. Our study aimed to investigate the risk factors and prevention of post-ERCP cholangitis.

METHODS

We retrospectively analyzed 4234 cases undergone ERCP in the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2008 to December 2013. Patient-related factors and procedure-related factors were analyzed to find the risk factors of post-ERCP cholangitis. The time point of post-ERCP cholangitis was also analyzed. Univariate and multivariate analyses were performed to define the independent risk factors of post-ERCP cholangitis.

RESULTS

The success rate of ERCP was 96.8% (4099/4234). The overall complication rate was 9.4% (399/4234). Post-ERCP cholangitis occurred in 102 cases (2.4%, 102/4234). The most dangerous time of post-ERCP cholangitis was from 24 h-48 h after ERCP (45.1%, 46/102). Univariate analysis revealed that age, hypertension, diabetes, previous ERCP history, biliary stent insertion, pancreatography, endoscopic sphincterotomy, balloon dilation and hilar obstruction were risk factors of post-ERCP cholangitis (P < 0.05). Multivariate analysis indicated that age, previous ERCP history and hilar obstruction were independent risk factors (P < 0.05). While endoscopic stone extraction was the potential protective factor.

CONCLUSIONS

Many risk factors are involved in post-ERCP cholangitis. Among them, old age, previous ERCP history and hilar obstruction were independently related to this post-ERCP complication.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries

BACKGROUND/PURPOSE

The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients.

METHODS

We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.

RESULTS

We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers.

CONCLUSIONS

AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

Subclinical focal Cholangitis mimicking liver metastasis in asymptomatic patients with history of pancreatic Ductal Adenocarcinoma and Biliary tree intervention

BACKGROUND

Cholangitis is an inflammatory process of the biliary tract with a wide range of clinical manifestations and it is not always considered in the differential diagnosis in asymptomatic patients. To the best of our knowledge there is no previous report in the English literature of focal cholangitis manifesting exclusively as liver parenchymal changes mimicking liver metastasis in asymptomatic patients with pancreatic ductal adenocarcinoma (PDAC) and history of manipulation of the biliary tree. The purpose of this article is to present six cases of subclinical focal cholangitis mimicking liver metastasis in asymptomatic patients with history of PDAC and biliary tree intervention.

CASE PRESENTATION

There are six cases with new hepatic lesions detected on follow-up scans in asymptomatic patients with history of PDAC and manipulation of biliary tree. Overall seven lesions were detected, all of them were on the liver periphery, five were hypovascular and two were hypervascular. None of those patients had elevation of CA 19.9 compared with the previous exams. The three patients that had magnetic resonance imaging presented restriction on diffusion weighted imaging and high signal intensity on T2-weighted image. Two patients underwent liver biopsy, which showed only inflammatory changes. All patients were treated with antibiotics and underwent imaging follow-up, which demonstrated resolution of the lesions. None of the patients showed imaging or clinical signs of disease progression during this interval.

CONCLUSION

Radiologists and oncologists need to be aware of the possibility of focal cholangitis causing hepatic lesions mimicking neoplasia in patients with history of biliary tree intervention, even in the absence of clinical symptoms.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Secondary sclerosing cholangitis in critically ill patients: current perspectives

Secondary sclerosing cholangitis (SSC) is a term used for a group of chronic cholestatic disease affecting the intra- and/or extrahepatic biliary tree with inflammation and progressive stricture formation, which can lead to biliary cirrhosis. A newly recognized form of SSC is secondary sclerosing cholangitis in critically ill patients (SSC-CIP). Pathogenesis is believed to involve ischemic injury of intrahepatic bile ducts associated with prolonged hypotension, vasopressors administration, and/or mechanical ventilation in patients treated in the intensive care unit (ICU). Patients diagnosed with SSC-CIP have no prior history of liver disease and no known pathologic process or injury responsible for bile duct obstruction prior to ICU treatment. Reasons leading to ICU treatment are many including multitrauma, burn injury, cardiac surgery, severe pneumonia, other infections, or bleeding after abdominal surgery. Patients have in common prolonged ICU admission. SSC-CIP is associated with rapid progression to liver cirrhosis and poor survival with limited treatment options except a liver transplantation. Transplant-free survival is around 17-40 months, which is lower than in other SSC patients. During the initial stages of the disease, the clinical symptoms and biochemical profile are not specific and easily missed. Biliary casts formation may be considered pathognomonic for SSC-CIP since most patients have them in early stages of the disease. Increased awareness and early detection of the disease and its complications is considered to be crucial to improve the poor prognosis.

Impact of inadequate initial antimicrobial therapy on mortality in patients with bacteraemic cholangitis: a retrospective cohort study

OBJECTIVES

Acute cholangitis is a common cause of bacteraemia resulting in severe sepsis or septic shock. The impact of the appropriate initial antimicrobial therapy on short-term mortality in bacteraemic cholangitis has not been well investigated.

METHODS

We conducted a retrospective cohort study of patients with bacteraemic cholangitis at two large tertiary care centres in Tokyo, Japan between 2009 and 2015. We determined the factors associated with 30-day all-cause mortality from the date of drawing the first positive blood culture, using a multivariate logistic regression analysis.

RESULTS

We identified 573 patients with bacteraemic cholangitis (median age, 77 years; male, 58.3%). The 30-day all-cause mortality rate was 6.6% (38/573). Inadequate initial antimicrobial therapy occurred in 133 (23.2%) patients. Factors associated with 30-day all-cause mortality included the Charlson co-morbidity index score >3 (adjusted odds ratio (aOR) 4.12; 95% CI 1.18-14.38), jaundice (total bilirubin >2.5 mg/dL) (aOR 3.39; 95% CI 1.46-7.89), septic shock within 48 h of the first positive blood culture (aOR 3.34; 95% CI 1.42-7.89), biliary obstruction due to hepatobiliary malignancy (aOR 8.00; 95% CI 2.92-21.97), and inadequate initial antimicrobial therapy (aOR 2.78; 95% CI 1.27-6.11).

CONCLUSIONS

Inadequate initial antimicrobial therapy was an important, modifiable determinant of survival.

Cholangitis in the postoperative course after biliodigestive anastomosis

BACKGROUND

Hepatobiliary surgery with biliodigestive anastomosis (BDA) results in a loss of the sphincter of Oddi with consecutive ascension of bacteria into the bile system which may cause cholangitis in the postoperative course.

METHODS

Patients who received reconstruction with a BDA after hepatobiliary surgery were analyzed retrospectively for their postoperative course of disease depending on intraoperatively obtained bile cultures and antibiotic prophylaxis.

RESULTS

Two hundred forty-three patients were included in the analysis, 49.4 % of whom had received endoscopic stenting before the operation. Stenting was significantly associated with the presence of drug-resistant bacteria in the intraoperatively obtained bile sample (p < 0.001, OR = 4.09). Of all patients, 14.4 % developed postoperative cholangitis. This was significantly associated with the postoperative length of stay in the intensive care unit (p = 0.002, OR = 1.035). The highest incidence of postoperative cholangitis was found in patients with cholangiocellular carcinoma (n = 12, p = 0.046, OR = 2.178). Patients were more likely to harbor strains with resistance against the antibiotic that was given intraoperatively.

CONCLUSION

The risk for the presence of drug-resistant bacteria is increased by preoperative stenting of the common bile duct. Bile culture by intraoperative swabs can be altered by the perioperative antibiotic prophylaxis as it induces microbiological selection in the common bile duct.

Changes in causative pathogens of acute cholangitis and their antimicrobial susceptibility over a period of 6 years

BACKGROUND/AIMS

We evaluated changes of causative pathogen in acute cholangitis and their antimicrobial susceptibility over six years and differences between community-acquired and hospital-acquired acute cholangitis at our institution.

METHODS

Medical records of 1,596 patients with acute cholangitis and biliary drainage between August 2006 and August 2012 were reviewed retrospectively. Cases were divided according to time: period 1 (August 2006-December 2008, n=645, 40.4%), period 2 (January 2009-August 2012, n=951, 59.6%). Cases were divided according to community-acquired cholangitis (n=1,397, 87.5%) and hospital-acquired cholangitis (n=199, 12.5%). Causative pathogens and antimicrobial susceptibility were investigated in each group.

RESULTS

Causative pathogen was isolated from bile culture in 1,520 out of 1,596 cases (95.2%). The three most frequently isolated Gram-negative bacteria were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (n=485, 30.4%), E. coli (n=237, 13.2%), and Citrobacter freundii (n=110, 6.9%). Between periods 1 and 2, prevalence of ESBL-producing E. coli and Klebsiella pneumoniae did not show significant change (36.7% vs. 32.1%, p=0.073; 6.6% vs. 6.2%, p=0.732). C. freundii showed a significant increase from period 1 to period 2 (1.7% vs. 13.2%, p=0.000). In both time periods, imipenem was the antimicrobial agent showing the highest rate of susceptibility (93.3% vs. 93.9%, p=0.783). Higher prevalence of ESBL-producing E. coli and C. freundii was observed in the hospital-acquired cholangitis group (52.1% vs. 31.2%, p=0.000; 15.9% vs. 7.3%, p=0.001).

CONCLUSIONS

The most common causative pathogen of acute cholangitis was ESBL-producing E. coli. Prevalence of C. freundii increased over the time period. Imipenem should be reserved as an alternative for resistant pathogens.

Mortality Risk for Acute Cholangitis (MAC): a risk prediction model for in-hospital mortality in patients with acute cholangitis

Background

Acute cholangitis is a life-threatening bacterial infection of the biliary tract. Main focus of this study was to create a useful risk prediction model that helps physicians to assign patients with acute cholangitis into different management groups.

Methods

981 cholangitis episodes from 810 patients were analysed retrospectively at a German tertiary center.

Results

Out of eleven investigated statistical models fit to 22 predictors, the Random Forest model achieved the best (cross-)validated performance to predict mortality. The receiver operating characteristics (ROC) curve revealed a mean area under the curve (AUC) of 91.5 %. Dependent on the calculated mortality risk, we propose to stratify patients with acute cholangitis into a high and low risk group. The mean sensitivity, specificity, positive and negative predictive value of the corresponding optimal cutpoint were 82.9 %, 85.1 %, 19.0 % and 99.3 %, respectively. All of these results emerge from nested (cross-)validation and are supposed to reflect the model’s performance expected for external data. An implementation of our risk prediction model including the specific treatment recommendations adopted from the Tokyo guidelines is available on http://www2.imse.med.tum.de:3838/.

Conclusion

Our risk prediction model for mortality appears promising to stratify patients with acute cholangitis into different management groups. Additional validation of its performance should be provided by further prospective trails.

Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis

BACKGROUND

Predictors of organ failure and the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis are unclear.

AIM

To identify factors associated with persistent organ failure and assess the impact of early ERCP on outcomes in hospitalised patients with cholangitis.

METHODS

Consecutive hospitalised patients who received ERCP at two centres for cholangitis from 4/2005-3/2013 were retrospectively reviewed. Delayed ERCP was defined as ERCP ≥ 48 h after hospitalisation. Primary outcome was persistent organ failure at >48 h after hospitalisation (≥ 1.5 times rise in creatinine levels from baseline values to ≥ 1.5 mg/dL or need for dialysis, mechanical ventilation and/or hypotension requiring vasopressor).

RESULTS

203 patients (mean age 59 ± 19 years) had ERCP for cholangitis: 115 with choledocholithiasis, 48 with other benign obstructions and 40 with malignant strictures. Forty-five (22%) patients had persistent organ failure at >48 h and 11 (5%) died. On multivariate analysis, Charlson Comorbidity Index >2 (OR = 4.6, 95% CI = 1.5-13.8), systemic inflammatory response syndrome (SIRS; OR = 3.2, 95% CI = 1.1-9.8), hypoalbuminemia (OR = 3.3, 95% CI = 1.4-7.9), bacteremia (OR = 2.8, 95% CI 1.3-6.2) and delayed ERCP(OR = 3.1, 95% CI: 1.4-7.0) were associated with persistent organ failure. Every 1-day delay in ERCP was associated with a 17% (95% CI = 5-29%) relative risk increase in persistent organ failure after adjusting for significant factors.

CONCLUSIONS

Delay in ERCP beyond 48 h was associated with persistent organ failure in hospitalised patients with acute cholangitis. Other factors included increased comorbidities, SIRS, hypoalbuminemia and bacteremia. Early ERCP performed within 48 h after presentation in patients with cholangitis may improve outcomes.

MR imaging of the biliary system

Although ultrasound, computed tomography, and cholescintigraphy play essential roles in the evaluation of suspected biliary abnormalities, magnetic resonance (MR) imaging and MR cholangiopancreatography can be used to evaluate inconclusive findings and provide a comprehensive noninvasive assessment of the biliary tract and gallbladder. This article reviews standard MR and MR cholangiopancreatography techniques, clinical applications, and pitfalls. Normal biliary anatomy and variants are discussed, particularly as they pertain to preoperative planning. A spectrum of benign and malignant biliary processes is reviewed, emphasizing MR findings that aid in characterization.

Streptococcus bovis group and biliary tract infections: an analysis of 51 cases

Streptococcus bovis is a well-known cause of endocarditis, but its role in other infections has not been well described. We analysed prospectively all patients with biliary tract infections caused by S. bovis group during the period 1988-2011. We selected those cases associated with cholangitis and cholecystitis, defined according to Tokyo guidelines. Identification of the strains was performed using the API 20 Strep and the GP card of the Vitek 2 system, and was confirmed by molecular methods. Our series included 51 cases (30 cholangitis and 21 cholecystitis). The associated microorganisms were: Streptococcus infantarius (biotype II/1) 29 cases (57%), Streptococcus gallolyticus subsp. pasteurianus (biotype II/2) 20 cases (39%) and Streptococcus gallolyticus subsp. gallolyticus (biotype I) two cases (4%). The only difference found between S. infantarius and S. gallolyticus subsp. pasteurianus was a greater association of the first with malignant strictures of the bile ducts: 48% (14/29) versus 5% (1/20), p <0.001. Thirty-seven of the cases also had bacteraemia, causing 20% (37/185) of all S. bovis bacteraemia, with differences between S. gallolyticus subsp. gallolyticus (2/112; 2%) and the other two microorganisms: S. infantarius and S. gallolyticus subsp. pasteurianus (35/73; 48%; p <0.001). The vast majority of biliary tract infections due to S. bovis group are caused by S. infantarius and S. gallolyticus subsp. pasteurianus (S. bovis biotype II), and nearly half of the bacteraemia due to these two species has a biliary source (43% of the S. infantarius and 56% of S. gallolyticus subsp. pasteurianus).

Management for CBD stone-related mild to moderate acute cholangitis: urgent versus elective ERCP

BACKGROUND

There is no doubt that urgent biliary decompression needs to be done in case of severe acute cholangitis. However, it remains to be determined how early biliary decompression should be performed and elective intervention would be comparable to urgent intervention, in case of mild to moderate choledocholithiasis associated cholangitis.

METHODS

One hundred ninety-five patients were enrolled who were diagnosed with mild to moderate cholangitis with common bile duct (CBD) stones between January 2006 and August 2010. They were divided into two groups according to door to intervention time, and urgent (≤24 h, n = 130) versus elective (>24 h, n = 82). Primary outcomes of this study were technical success rate (CBD stones removal) and clinical success rate (improvement of cholangitis) between the two groups. Hospital stay and intervention-related complications were also evaluated.

RESULTS

There was no statistically significant difference in technical, clinical success rate and intervention-related complications between the urgent and elective groups (P = 0.737, 0.285, 0.398, respectively). Patients in the urgent group had significantly shorter hospitalization than in the elective group (6.8 vs. 9.2 days, P < 0.001), and furthermore, intervention to discharge time was also significantly shorter by 1.1 days in the urgent group (P = 0.035). In terms of laboratory parameters, initial CRP level was the only factor correlated with hospital stay and intervention to discharge time.

CONCLUSIONS

This study demonstrates that urgent ERCP would be recommended in the management of patients with CBD stone-related mild to moderate acute cholangitis because of the advantage of short hospital stay and intervention to discharge time.

Infections of the biliary tract

Infection of the biliary tract, or cholangitis, is a potentially life-threatening condition. Bile duct stones are the most common cause of biliary obstruction predisposing to cholangitis. The key components in the pathogenesis of cholangitis are biliary obstruction and biliary infection. Several underlying mechanisms of bactibilia have been proposed. Characteristic clinical features of cholangitis include abdominal pain, fever, and jaundice. A combination of clinical features with laboratory tests and imaging studies are frequently used to diagnose cholangitis. Endoscopic retrograde cholangiopancreatography is the best diagnostic test. Less invasive imaging tests may be performed initially in clinically stable patients with uncertain diagnoses.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines

BACKGROUND

The Tokyo Guidelines for the management of acute cholangitis and cholecystitis were published in 2007 (TG07) and have been widely cited in the world literature. Because of new information that has been published since 2007, we organized the Tokyo Guidelines Revision Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines (TG13).

METHODS/MATERIALS

We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was suspected. The cases were collected from multiple tertiary care centers in Japan. The 'gold standard' for acute cholangitis in this study was that one of the three following conditions was present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or (3) remission was achieved by antibacterial therapy alone, in patients in whom the only site of infection was the biliary tree. Comparisons were made for the validity of each diagnostic criterion among TG13, TG07 and Charcot's triad.

RESULTS

The major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from 82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of Charcot's triad was only 26.4 % but the specificity was 95.6 %. However, the false positive rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading, Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors which were derived from evidence presented recently in the literature. The factors chosen allow severity assessment to be performed soon after diagnosis of acute cholangitis.

CONCLUSION

TG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.

Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients

AIM: To identify the frequency of bacterial growth, the most commonly grown bacteria and their antibiotic susceptibility, and risk factors for bacterial colonization in bile collected from patients with different biliary diseases.

METHODS: This prospective study was conducted between April 2010 and August 2011. Patients with various biliary disorders were included. Bile was aspirated by placing a single-use, 5F, standard sphincterotome catheter into the bile duct before the injection of contrast agent during endoscopic retrograde cholangiopancreaticography (ERCP). Bile specimens were transported to the microbiology laboratory in blood culture bottles within an anaerobic transport system. Bacteria were cultured and identified according to the standard protocol used in our clinical microbiology laboratory. The susceptibilities of the organisms recovered were identified using antimicrobial disks, chosen according to the initial gram stain of the positive cultures.

RESULTS: Ninety-one patients (27% male, mean age 53.7 ± 17.5 years, range: 17-86 years) were included in the study. The main indication for ERCP was benign biliary disease in 79 patients and malignant disease in 12 patients. The bile culture was positive for bacterial growth in 46 out of 91 (50.5%) patients. The most frequently encountered organisms were Gram-negative bacteria including Escherichia coli (28.2%), Pseudomonas (17.3%) and Stenotrophomonas maltophilia (15.2%). There were no significant differences between patients with malignant and benign disease (58% vs 49%, P = 0.474), patients with acute cholangitis and without acute cholangitis (52.9% vs 50%, P = 0.827), patients who were empirically administered antibiotics before intervention and not administered (51.4% vs 60.7%, P = 0.384), with regard to the bacteriobilia. We observed a large covering spectrum or low resistance to meropenem, amikacin and imipenem.

CONCLUSION: We did not find a significant risk factor for bacteriobilia in patients with biliary obstruction. A bile sample for microbiological analysis may become a valuable diagnostic tool as it leads to more accurate selection of antibiotics for the treatment of cholangitis.

Emergency endoscopic intervention versus surgery in the management of acute obstructive suppurative cholangitis

AIM: To compare the curative effect between emergency endoscopic intervention and surgery in the management of acute obstructive suppurative cholangitis (AOSC).

METHODS: The clinical data for 72 patients with AOSC who were treated at our hospital from November 2008 to June 2011 were analyzed retrospectively. Of these patients, 54 underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) (group 1), and 18 underwent biliary decompression and T-tube drainage (group 2).

RESULTS: The average age of all patients was 68.3 years ± 14.2 years. The causes of AOSC were gallstones (88.9%) and malignant biliary strictures (11.1%). There were no statistical significances between group 1 and group 2 in age and distribution of sex and etiology (all P > 0.05); however, there were statistical differences between the two groups in success rate (94.4% vs 72.2%), complication rate (3.7% vs 27.8%), mortality rate (0 vs 16.7%), postoperative hospital stay (9.1 d ± 8.0 d vs 16.2 d ± 9.9 d), and cost of hospitalization (36.4 thousand RMB ± 15.2 thousand RMB vs 93.3 thousand RMB ± 68.6 thousand RMB) (all P < 0.05).

CONCLUSION: Emergency endoscopic intervention is superior to surgery in increasing success rate and decreasing complication and mortality rate in the management of AOSC.

Epidemiology and prognostic determinants of bacteraemic biliary tract infection

OBJECTIVES

To determine the epidemiology of bacteraemia due to biliary tract infection (BTI) and to identify independent predictors of mortality.

METHODS

This study was part of a bloodstream infection surveillance study that prospectively collected data on consecutive patients with bacteraemia in our institution from 1991 to 2010. BTI was the confirmed source of 1373 patients with bacteraemia, and the independent prognostic factors of 30 day mortality were determined.

RESULTS

The mean age of patients with biliary sepsis was 71 years (± 14 years). The most frequent comorbidities were biliary lithiasis and solid-organ cancer [484 cases (35%) and 362 cases (26%), respectively]. The BTI was healthcare-associated in 33% of patients. Shock and mortality accounted for 209 and 126 cases, respectively (15% and 9%). The most frequent microorganisms isolated were Escherichia coli (749, 55%), Klebsiella spp. (240, 17%), Enterococcus spp. (171, 12%), Pseudomonas aeruginosa (86, 6%) and Enterobacter spp. (63, 5%). There were 47 (3%) cefotaxime-resistant (CTX-R) E. coli or Klebsiella spp. Inappropriate empirical antibiotic treatment was an independent factor associated with mortality (OR 1.4, 95% CI 1.1-1.7). Inappropriate empirical treatment was more frequent in P. aeruginosa and CTX-R Enterobacteriaceae bacteraemia. These microorganisms were significantly more common in patients with previous antibiotic therapy, solid-organ cancer or transplantation and in healthcare-associated bacteraemia.

CONCLUSIONS

In patients with bacteraemic BTI, inappropriate empirical therapy was more frequent in P. aeruginosa and CTX-R Enterobacteriaceae infection and was associated with a higher mortality rate. In patients with bacteraemia due to BTI and solid-organ cancer or transplantation, healthcare-associated infection or previous antibiotic treatment, initial therapy with piperacillin/tazobactam or a carbapenem would be advisable.

The clinical epidemiology and outcomes of bacteremic biliary tract infections caused by antimicrobial-resistant pathogens

OBJECTIVES

The prevalence of antibiotic-resistant pathogens continues to increase steadily. The aim of this study was to analyze the changing patterns and risk factors of antibiotic resistance in patients with bacteremic biliary tract infections (BTIs). In addition, prognostic factors related to survival in patients with a bacteremic BTI were evaluated.

METHODS

Five hundred fifty-six biliary bacteremic events in 411 patients, treated from January 2000 to April 2010, were retrospectively analyzed. In addition, biliary bacteremic events were divided into nosocomial infections (N=396) and community-acquired infections (N=160).

RESULTS

The resistance rate to third-generation cephalosporin was higher in 2005-2009 (35 out of 140, 25%, vs. 72 out of 151, 47.7%). The prevalence of extended-spectrum β-lactamase-producing organisms of Escherichia coli and Klebsiella strains increased markedly from 2.3% (2 out of 86) in 2000-2004 to 43.9% (58 out of 132) in 2005-2009. Nosocomial infection, hospital days before bacteremia, previous hospitalization within 90 days, previous use of antibiotics within 90 days, and an indwelling biliary drainage catheter were found to be independently associated with antibiotic resistance. However, no association was found between antibiotic resistance and mortality in patients with biliary bacteremia.

CONCLUSIONS

Antibiotic resistance in bacteremic BTI has increased markedly during the past 10 years. Almost half of nosocomial bacteremic BTI caused by common Gram-negative pathogens during 2005-2009 (58.5%) could not be treated with third-generation cephalosporin. Clinical outcomes were found to be associated with bacteremia severity and underlying illness rather than antibiotic resistance.

Fever-based antibiotic therapy for acute cholangitis following successful endoscopic biliary drainage

BACKGROUND

The current management of acute cholangitis consists of antibiotic therapy in combination with biliary drainage. However, the optimal duration of antibiotic therapy after the resolution of clinical symptoms by biliary drainage is unclear. We aimed to evaluate whether discontinuing antibiotic therapy for acute cholangitis immediately after the resolution of clinical symptoms, achieved by endoscopic biliary drainage, was safe and effective.

METHODS

This prospective study included patients with moderate and severe acute cholangitis. Cefmetazole sodium and meropenem hydrate were used as initial antibiotic therapy for patients with moderate and severe acute cholangitis, respectively. All patients underwent endoscopic biliary drainage within 24 h of diagnosis. When the body temperature of < 37 ° C was maintained for 24 h, administration of antibiotics was stopped. The primary endpoint was the recurrence of acute cholangitis within 3 days after the withdrawal of antibiotic therapy.

RESULTS

Eighteen patients were subjected to the final analysis. The causes of cholangitis were bile duct stone (n = 17) and bile duct cancer (n = 1). The severity of acute cholangitis was moderate in 14 patients and severe in 4. Body temperature of < 37 ° C was achieved in all patients after a median of 2 days (range 1-6) following endoscopic biliary drainage. Antibiotic therapy was administered for a median duration of 3 days (range 2-7). None of the patients developed recurrent cholangitis within 3 days after the withdrawal of antibiotics.

CONCLUSIONS

Fever-based antibiotic therapy for acute cholangitis is safe and effective when resolution of fever is achieved following endoscopic biliary drainage.