Microbiological Assessment of Bile and Corresponding Antibiotic Treatment: A Strobe-Compliant Observational Study of 1401 Endoscopic Retrograde Cholangiographies

The aim of this study was to determine the antibiotic susceptibility profiles of bacteria in bile samples and to analyze the clinical relevance of the findings as only limited information about risk factors for elevated frequence of bacterial and fungal strains in routinely collected bile samples has been described so far.A prospective cohort study at a tertiary care center was conducted. Seven hundred forty-four patients underwent 1401 endoscopic retrograde cholangiographies (ERCs) as indicated by liver transplantation (427/1401), primary sclerosing cholangitis (222/1401), choledocholithiasis only (153/1401), obstruction due to malignancy (366/1401), or other conditions (233/1401). Bile samples for microbiological analysis were obtained in all patients.The 71.6% (823/1150) samples had a positive microbiological finding, and 57% (840/1491) of the bacterial isolates were gram-positive. The main species were Enterococcus spp (33%; 494/1491) and Escherichia coli (12%; 179/1491). Of the samples, 53.8% had enteric bacteria and 24.7% had Candida spp; both were associated with clinical and laboratory signs of cholangitis (C-reactive proteins 35.0 ± 50.1 vs 44.8 ± 57.6; 34.5 ± 51.2 vs 52.9 ± 59.7; P < 0.001), age, previous endoscopic intervention, and immunosuppression. Multi-resistant (MR) strains were found in 11.3% of all samples and were associated with clinical and laboratory signs of cholangitis, previous intervention, and immunocompromised status. In subgroup analysis, strain-specific antibiotic therapy based on bile sampling was achieved in 56.3% (89/158) of the patients. In cases with a positive bile culture and available blood culture, blood cultures were positive in 29% of cases (36/124), and 94% (34/36) of blood cultures had microbial species identical to the bile cultures.Bactobilia and fungobilia can usually be detected by routine microbiological sampling, allowing optimized, strain-specific antibiotic treatment. Previous endoscopic intervention, clinical and laboratory signs of cholangitis, and age are independent risk factors. MR bacteria and fungi are an evolving problem in cholangitis, especially in immunocompromised patients.

[Biliary pathology. Key aspects of the problem]

Based on the clinical experience gained in the Department of Pathology biliary tract, Central Research Institute of Gastroenterology, were reviewed key aspects of biliary pathology on the issues of classification, diagnosis, treatment, and tactics for management of patients with various diseases of the biliary tract.

[Current aspects of diseases biliary tract in childhood]

This article describes the current status of the issue of biliary tract disease in children. There were shown current differences according to age-appropriate. Was presented a new structure of the bile-excreting system diseases, among them dysfunction of the gallbladder and Oddi's sphincter, bile duct abnormalities, biliary sludge, cholelithiasis; cholesterosis of the gall bladder isn't casuistry. Was established necessity of modern intrascope research methods for the differential diagnosis of these diseases. Were identified promising areas of study of biliary tract diseases in childhood.

[Major achievements of biliary science for 40 years]

The review presents data on major achievements in the field of biliary pathology studies for the past 40 years. The article consists of several sections: choleresis and biliary excretion, pathogenesis, clinical picture, diagnostics and treatment. The article also discloses major achievements in biliary pathology studies of both foreign and native researchers including the contribution made by researchers from the Central Research Institute of Gastroenterology. In vitro study of the acid neutralizing effect of antiacid drugs.

Biliary complications following liver transplantation: single-center experience

Biliary complications (BC) following orthotopic liver transplantation (OLT) remain one of the major causes of postoperative complications and treatment failures. The list of common BC consists of biliary stricture, fistula, ischemic type biliary lesions (ITBL), cholangitis, and bile leakage following T-drain removal. Between July 2000 and December 2004, 101 consecutive cadaveric OLTs were performed in our institution. All but three were first full-size grafts. Seventeen patients were transplanted from the urgent list, the remaining 84 (83.16%) from the elective list. All but three patients had a choledochocholedochostomy over a straight drain. Bile cultures were taken routinely. The bile drain was removed following cholangiography 6 weeks after OLT. All patients received antibiotic prophylaxis. Ursodeoxycholic acid was used in selected cases. During the first 6 weeks positive bile cultures in absence of clinical and biochemical symptoms of cholangitis were found in 61 (60.4%) cases. Symptomatic cholangitis requiring antibiotic treatment was observed in 19 (18.8%) patients during the first 6 weeks. Two patients required endoscopic sphincterotomy and temporary stenting due to anastomotic stricture (1) or papilla of Vater fibrosis (1). Bile leakage following drain removal was observed in 8 (7.9%) patients. Five of them were treated conservatively, the remaining 3 (2.9%) required surgery (lavage) and stenting. In one case extrahepatic bile duct necrosis was diagnosed requiring reconstruction of the biliary anastomosis. No case of ITBL, bile leak at the anastomostic site, or stricture requiring surgical repair was noted. Despite the high incidence of positive bile cultures most likely related to use of a drain, the overall number of BC was low.

Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment

Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.

T-tube removal after liver transplantation: a new technique that reduces biliary complications

This article discusses a new simple, fast, and easily performed technique that allows reduction of morbidity and hospital stay after T-tube removal. A retrospective analysis was conducted of 145 recipients who underwent T-tube removal 3 months after orthotopic liver transplantation. Patients were divided in two groups: group 1 (n=93) underwent T-tube removal and contemporary placement under fluoroscopic guidance of a counter-drain. Group 2 (n=52) T-tubes were removed from the bile duct under fluoroscopy but were left in place as a counter-drain. Overall, there were 33 (22.7%) complications related to T-tube removal. Treatment was always conservative and no deaths were related to T-tube. In group 1, 29 (31.2%) complications occurred; and the mean hospital stay was 9.4+/-9.3 days. In group 2, four complications (7.7%) occurred (P=0.002); and the mean hospital stay was 5.8+/-5.5 days (P=0.012). The adoption of this new technique-under fluoroscopic guidance, using the T-tube itself as a counter-drain-for T-tube removal allowed us to significantly reduce biliary complications and hospital stay.

Long-term results of metallic stents for benign biliary strictures

BACKGROUND

Historically, surgical correction has been the treatment of choice for benign biliary strictures (BBS). Self-expandable metallic stents (MSs) have been useful for inoperable malignant biliary strictures; however, their use for BBS is controversial and their natural history unknown.

HYPOTHESIS

To test our hypothesis that MSs provide only short-term benefit, we examined the long-term outcome of MSs for the treatment of BBS. Our goal was to develop a rational approach for treating BBS.

DATA EXTRACTION

Between July 1990 and December 1995, 15 patients had MSs placed for BBS and have been followed up for a mean of 86.3 months (range, 55-120 months). The mean age of the patients was 66.6 years and 12 were women. Stents were placed for surgical injury in 5 patients and underlying disease in 10 patients (lithiasis, 7; pancreatitis, 2; and primary sclerosing cholangitis, 1). One or more MSs (Gianturco-Rosch "Z" for 4 patients and Wallstents for 11 patients) were placed by percutaneous, endoscopic, or combined approaches. We considered patients to have a good clinical outcome if the stent remained patent, they required 2 or fewer invasive interventions, and they had no biliary dilation on subsequent imaging.

DATA SYNTHESIS

Metallic stents were successfully placed in all 15 patients, and the mean patency rate was 30.6 months (range, 7-120 months). Five patients (33%) had a good clinical result with stent patency from 55 to 120 months. Ten patients (67%) required more than 2 radiologic and/or endoscopic procedures for recurrent cholangitis and/or obstruction (range, 7-120 months). Five of the 10 patients developed complete stent obstruction at 8, 9, 10, 15, and 120 months and underwent surgical removal of the stent and bilioenteric anastomosis. Four of these 5 patients had strictures from surgical injuries. The patient who had surgical removal 10 years after MS placement developed cholangiocarcinoma.

CONCLUSIONS

Surgical repair remains the treatment of choice for BBS. Metallic stents should only be considered for poor surgical candidates, intrahepatic biliary strictures, or failed attempts at surgical repair. Most patients with MSs will develop recurrent cholangitis or stent obstruction and require intervention. Chronic inflammation and obstruction may predispose the patient to cholangiocarcinoma.

Pancreatic-biliary imaging and triage

The pancreas and biliary tree (and their confluence at the papilla of Vater) are frequent sites for disease. In recent years there has been a proliferation of relevant technologies. Diagnostic methods include percutaneous ultrasound, standard CT scans, helical CT, magnetic resonance imaging, MRCP, endoscopic ultrasound, angiography, ERCP, laparoscopy, and laparoscopic ultrasound. Cytology and biopsy specimens can be taken in conjunction with many of these techniques. In addition to standard open surgical intervention, there are now many alternative therapeutic approaches wielded by endoscopists, interventional radiologists and laparoscopic surgeons. Novel chemotherapy and radiation oncology techniques and further dimensions. Many studies have attempted to evaluate the role of one particular modality, or to compare two diagnostic or therapeutic techniques. It is more important (and more difficult) to devise and test relevant management algorithms. These assessments are bedevilled by the problem of generalizability, since the results of many techniques are operator-dependent. This raises another issue-whether patients with these problems should be managed in regional specialty centers. Another complexity is that the management of a particular problem is influenced not only by the disease and its stage but also by the type of patient in whom it occurs (age, comorbidities, etc.). Multidisciplinary collaboration is a great challenge (12, 13).

Clinical diversity in biliary pancreatitis--classification of two types

One hundred and seven patients with biliary pancreatitis undergoing operation from 1976 to 1989 were reviewed. To clarify the reason for failure to respond to conventional supportive therapy, 73 patients (68%) who underwent emergency surgery were retrospectively divided into two groups according to the severity of the pancreatitis evaluated at laparotomy and compared. Sixty-two had minimal or mild pancreatitis (Group I), among whom 44 (71%) had life-threatening acute biliary tract disease. All underwent biliary surgery and 4 (6%) subsequently died, 2 due to acute obstructive suppurative cholangitis. Eleven had hemorrhagic necrotizing pancreatitis (Group II), among whom 7 had complications of acute pancreatitis such as pancreatic ascites or abscess. These underwent pancreatic and/or biliary surgery and 3 (27%) died of multi-organ failure. There appears to be two types of biliary pancreatitis refractory to conventional supportive therapy, which differ in the extent of surgery required and in mortality: (1) minimal or mild pancreatitis with persistent life-threatening acute biliary tract disease (biliary type), and (2) more severe pancreatitis (pancreas type) early in the course of the disease.

The accelerated diagnosis of jaundice with ultrasonography and narrow-needle cholangiography

The accuracy of ultrasonography in the diagnosis of jaundice in 70 patients has been compared with that of transhepatic cholangiography and the results of surgery and liver biopsy. A simplified system of grouping the ultrasonic data is presented. The results indicate that ultrasonography is capable of differentiating obstructive from non-obstructive jaundice in 94% of cases and of defining the correct anatomical level in 85% of cases. The accuracy of narrow-needle cholangiography was 100% for obstructive jaundice and 66% normal duct entry rate for non-obstructive jaundice.

[Combination of cystic dilatation of the hepatic, common, and intrahepatic bile ducts (author's transl)]

Common duct cysts are a rare entity. The combination of cystic alterations of the entire bile duct system is less known. Etiology, classification, and Roentgen signs are described in a case presentation with common duct cyst and marked ectasia of the intrahepatic bile ducts.

Can Mirizzi syndrome be classified into acute and chronic form? An endoscopic retrograde cholangiography (ERC) study

Three cases of Mirizzi syndrome (partial mechanical obstruction of the common hepatic duct owing to compression by a stone impacted in the cystic duct or gallbladder neck, or due to the inflammatory reaction resulting from compression) are reported. The roentgen features at endoscopic retrograde cholangiography (ERC) are discussed. As there are two causes for obstruction, compression or chronic fibrosing reaction resulting from compression, two characteristic X-ray findings and two operating techniques, the authors contend that Mirizzi syndrome should be classified as acute or chronic.

Congenital bile duct cysts: Classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst

Congenital bile duct cysts are observed in any part of the bile duct from the liver to the duodenum. Reports of cases of cancer arising from it are increasing. Excision of the choledochal cyst seems to be the treatment of choice and partial resection of the intrahepatic cyst followed by intrahepatic cystoenterostomy at the porta hepatis is necessary for type IV-A cysts.

Choledochal cysts. A review of the cystic anomalies of the biliary tree

Congenital cysts of the biliary tree, although uncommon, are being reported in increasing numbers. The widely accepted classification would seem to warrant modification in the light of recent observations. The clinical spectrum of the condition is reviewed, together with the surgical approach to treatment and its indications and complications.