Acute Cholangitis: Causes, Diagnosis, and Management

Acute cholangitis, also referred to as ascending cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction. Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies. The treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct. Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcome of the disease. This article provides an update on early diagnosis and management of acute cholangitis.

Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Mucinous Cystic Neoplasm of the Liver and Extrahepatic Biliary Tract with Ascending Cholangitis: a Case Report and Review of the Literature

Mucinous cystic neoplasms of the liver involving the extrahepatic biliary tract is a rare slow-growing benign neoplasm of biliary system that has an early clinical presentation with obstructive jaundice. These tumors have a high risk of malignant transformation, which is difficult to diagnose preoperatively by radiology or endoscopy. We present a 31-year-old female patient who presented with complaints of pain abdomen, vomiting, fever, and obstructive jaundice. Ultrasound abdomen showed features suggestive of cholangitic abscess. Computed tomography abdomen showed features suggestive of cholangitic abscess and abrupt termination of the proximal CBD secondary to the stricture. A left hemi-hepatectomy was performed which showed a multiloculated cystic liver lesion with the involvement of extrahepatic duct, cystic duct, and proximal common bile duct. Histopathology showed cyst was lined by mucin secreting columnar epithelium without nuclear atypia, the wall the cysts showed ovarian-like stroma, and the diagnosis of mucinous cystic neoplasms of the liver and extrahepatic biliary tract with ascending cholangitis was made. Regular follow-up by clinical and radiological examination at 6 months did not reveal any recurrence.

A unusual case of multifocal pyogenic abscess formation following ERCP procedure

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death.

Case presentation

A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach .

Conclusions

Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.

Biliary Fascioliasis in Chronic Calcific Pancreatitis Presenting with Ascending Cholangitis and Biliary Stricture

Biliary fascioliasis is a rare infection of the hepatobiliary system. In human, it is known to present with two main phases; acute phase (hepatic phase) presenting with abdominal pain or abnormal liver biochemistry then chronic phase (biliary phase) presenting with biliary obstruction or cholangitis. Optimal treatment of biliary fascioliasis consists of endoscopic retrograde cholangiography with removal of the parasite and single oral dose of triclabendazole. We report a rare case of biliary fascioliasis in chronic calcified pancreatitis who presented with ascending cholangitis and biliary stricture. A 63-years-old Thai man was referred to our hospital for treatment of clinical symptoms severe cholangitis. Magnetic resonance cholangiopancreatography showed evidence of distal common bile duct stricture associated with chronic calcific pancreatitis. ERCP was performed, that found a few amorphous filling defects in the common bile duct and distal biliary stricture. After removal of the foreign body of what seems to be a fluke parasite followed with single oral dose triclabendazole thereafter, the clinical symptom was improved dramatically.

Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All

BACKGROUND

Bacteremia due to cholangitis can occur as a complication of biliary instrumentation. Biliary sepsis can result from frequent endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We hypothesized that routine use of antibiotics in patients who require frequent ERCPs leads to cholangitis resistant to empiric antibiotics used to treat biliary sepsis. We retrospectively reviewed patients with frequent biliary instrumentation and blood stream infection due to cholangitis. Conventional empiric antibiotics were defined as broad-spectrum antibacterial agents predominantly used for community-acquired infections and surgical prophylaxis. Broad-spectrum antibacterial agents used for hospital-onset/multidrug-resistant infections were defined as broad-spectrum MDR antibiotics.

RESULTS

Seventy-eight patients had bacteremia secondary to cholangitis from biliary obstruction. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis. Thirty-seven patients did not receive post-procedural antibiotics and forty-one patients did. Of the ones who did, 58% later had a bloodstream infection with bacteria resistant to the antibiotic used for prophylaxis, and 26 patients (63%) required a broad-spectrum MDR antibiotic for treatment. The number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broad-spectrum MDR antibiotics for treatment of cholangitis-associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend toward need for broad-spectrum MDR antibiotics for cholangitis-associated bacteremia, Chi-square 3.7, 0 0.0540.

CONCLUSION

Bacterial resistance to conventional empiric antibiotics is an emerging problem. Blood cultures are needed to guide therapy.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM

To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.

METHODS

Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.

RESULTS

Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.

CONCLUSION

This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

Abnormal presentation of ascending cholangitis

Ventriculo-peritoneal, -gallbladder, -pleural, -atrial, and -jugular shunts are all viable options in the treatment of hydrocephalus 1, 2, 3. Retrieval of these catheters can often be very difficult and may be unsuccessful or incomplete. Retained catheters can result in unforeseen and unexpected complications.

Mucinous cystic neoplasm of the liver with extrahepatic growth presenting with ascending cholangitis diagnosed by endoscopic ultrasound features: a case report

Background

Mucinous cystic neoplasm of the liver with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system that presents with a mass effect or is incidentally found on imaging. The tumor affects mostly the common hepatic duct, which is difficult to diagnose preoperatively by radiology, endoscopy, or cystic fluid analysis. Endoscopic ultrasound is a noninvasive tool for the evaluation of features of a cystic lesion and the extent of disease. Optimal treatment is complete tumor resection.

Case presentation

A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction. Multiple investigations were performed, including endoscopic retrograde cholangiography and magnetic resonance imaging. Endoscopic ultrasound showed a multiloculated cystic lesion with internal septations without communication to the bile duct, which helped to support a diagnosis of mucinous cystic neoplasm. Eventually, the pathological diagnosis made was mucinous cystic neoplasm of the bile duct. A follow-up clinical examination with imaging at 6 months revealed that the patient was asymptomatic and without recurrence.

Conclusions

We report a rare case of a patient with a large mucinous cystic neoplasm of the liver with extrahepatic growth causing biliary obstruction, which was diagnosed on the basis of endoscopic ultrasound features. Following definitive diagnosis, treatment with complete surgical resection using a multidisciplinary approach was successful.

Acute cholangitis - an update

Acute cholangitis is bacterial infection of the extra-hepatic biliary system. As it is caused by gallstones blocking the common bile duct in most of the cases, its prevalence is greater in ethnicities with high prevalence of gallstones. Biliary obstruction of any cause is the main predisposing factor. Diagnosis is established by the presence of clinical features, laboratory results and imaging studies. The treatment modalities include administration of intravenous fluid, antibiotics, and drainage of the bile duct. The outcome is good if the treatment is started early, otherwise it could be grave.