Septicemia from biliary tract infection

One hundred four strains of microorganisms were isolated from the blood in 76 episodes of septicemia originating from biliary tract infection. The 70 patients involved included 40 with acute cholecystitis without previous surgery, 17 with cholangitis following previous surgery, and 13 patients with malignant disease, with or without previous surgery. The most common organisms were Escherichia coli, Klebsiella, Streptococcus, and Proteus. Various streptococci, most of them from group D, were involved in 21% of the episodes. Twenty-five patients underwent surgery following the bacteremia. In ten of 12 operations performed shortly after the septicemia, bile culture yielded the same organism(s) as in the blood. The types of organisms in blood, and especially the important role of streptococci, must be taken into consideration when choosing antibiotics for therapy for and prevention of biliary septicemia.

Primary sclerosing cholangitis: symptomatic and cholangiographic improvement after peripheral drainage

Presented is a patient with primary sclerosing cholangitis, extrahepatic bile duct obstruction, and associated occlusion of the main portal vein, who was treated by peripheral biliary drainage. Radiological follow-up showed considerable improvement of the ductal strictures and bile excretion through the normal anatomical route. The patient remains well and anicteric 60 months after surgery.

Gallbladder disease in patients with primary sclerosing cholangitis

We evaluated the gallbladders of 121 patients who had well-documented primary sclerosing cholangitis. Sonograms, cholangiograms, and CT scans were reviewed, and the findings were correlated with surgical or autopsy findings, when available. Pathologic examination of the gallbladder was available in 55 (45%) of the 121 patients; of these, 49 (89%) had abnormal gallbladders. Ninety-three of the 121 patients had one or more radiologic examinations of the gallbladder: 77 had sonograms, 80 had cholangiograms, and 18 had CT scans. Seventy-five (62%) of the 121 patients had abnormal gallbladders on histologic examination or had positive findings on one or more imaging study. By excluding 25 patients who had histologic changes of borderline significance and/or patients who had thick-walled gallbladders attributable to end-stage liver disease, we concluded that 50 (41%) of the 121 patients had intrinsic abnormalities of the gallbladder. Thirty-two (26%) had gallstones, 18 (15%) had probable primary sclerosing cholangitis involving the gallbladder, and five (4%) had benign or malignant neoplasms. Our study indicates that gallbladder abnormalities are common among patients with primary sclerosing cholangitis, and sonography is the most useful technique for evaluating these conditions.

Plasmapheresis and haemodialysis in a case of septic cholangitis complicated by hepatic and renal failure. Case report

Plasmapheresis was used as a complement to conventional therapy in a patient with multiorgan failure and disseminated intravascular coagulation (DIC) following biliary obstruction and septic cholangitis. The patient's remarkable improvement after plasmapheresis suggests a beneficial influence on the pathophysiologic mechanisms. Plasmapheresis is concluded to inhibit DIC and eliminate endotoxins.

Sclerosing cholangitis in cystic fibrosis

Four of 102 patients with cystic fibrosis with symptoms or signs suggesting sclerosing cholangitis had typical findings at endoscopic retrograde cholangiography (ERC), indicating this syndrome. All patients had pulmonary symptoms, pancreatic insufficiency, and pathologic sweat test results. Three females (aged 15-20 years), two of whom had unspecific colitis, presented with abdominal pain, and a 25-year-old male patient was asymptomatic. Two of the patients had persistently and one patient only intermittently pathologic serum concentrations of transaminases and gamma-glutamyltransferase. The fourth patient, who only had a transient increase of standard liver function tests, showed no progress in any variable (including liver biopsy and ERC) for 3 years, indicating a benign course. Disturbances of the liver and biliary system are well-known complications in cystic fibrosis. Our observations indicate that sclerosing cholangitis is another expression of biliary tract involvement in this disease.

Primary sclerosing cholangitis in children: study of five cases and review of the literature

Primary sclerosing cholangitis in five children is described and 78 cases in the pediatric age group are reviewed. In 24% of the cases, primary sclerosing cholangitis is not associated with an underlying disease and may appear to be prolonged cholestasis of infancy. When an associated condition is present, chronic inflammatory bowel disease, in particular ulcerative colitis, is most common (47%). Histiocytosis X and a variety of immune disorders account for 15% and 10% of cases, respectively. Primary sclerosing cholangitis should be considered in the differential diagnosis of chronic liver disease in the pediatric age group, even in young infants. Results of this survey demonstrate that neither clinical features nor liver function tests are reliable diagnostic predictors, that histologic changes are often nonspecific, and that cholangiography is essential to establish the correct diagnosis.

Postoperative jaundice as a clue to unrecognized biliary tract obstruction

Postoperative jaundice is often a complex clinical problem of multifactorial origin. If underlying liver disease is present preoperatively, there is a greater likelihood of jaundice after surgery. We describe two patients: one with intrabiliary hepatocellular carcinoma and the other with primary sclerosing cholangitis. The underlying processes were unmasked after the development of jaundice in the postoperative period. These cases point out the importance of considering previously undiagnosed biliary tract obstruction in the differential diagnosis of postoperative jaundice.

Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.

Surgical management of strictures of the major bile ducts in recurrent pyogenic cholangitis

Definitive surgical procedures were performed on 46 patients with strictures of the major bile ducts: dilatation of strictures was undertaken in 6 patients, hepatotomy and plastic repair in 2, biliary-enteric anastomosis in 18, and liver resection with or without drainage for the rest of the biliary tree in 20 patients. The overall operative morbidity was 21.7 per cent. Two patients died within 30 days of operation. One patient died of septicaemia after emergency dilatation of stricture while another died of sepsis from a leakage after hepatotomy and plastic repair. The median follow-up for the 44 patients who survived the operation was 43 months. All strictures reformed after dilatation within 2 months. Acute cholangitis occurred in six patients, two after dilatation of strictures (with documented recurrent stone formation in one), two after biliary-enteric anastomosis and two after liver resection. Thus, good clinical results were obtained in 38 out of 44 patients (86.4 per cent).

Percutaneous transhepatic balloon dilatation of benign biliary strictures

Between February 1981 and June 1984, 15 patients with benign biliary strictures were treated with percutaneous transhepatic balloon dilatation. Three of these patients had received liver transplants. The treatment began with a course of balloon dilatation therapy, after which a stent catheter was left across the stricture. Six weeks later, after duct patency had been shown by cholangiography, the stent catheter was removed from all but two patients, both of whom had intrahepatic sclerosing cholangitis. After this procedure, six patients (40%), including two liver-transplant patients, were stricture-free after one treatment for periods ranging from 27 to 56 months, and were considered to be treatment successes. Nine patients (60%) suffered stricture recurrences. In eight of these patients, the stricture was heralded by symptoms of either cholangitis or jaundice; in one patient, who was on permanent catheter drainage, the stricture was discovered only on follow-up cholangiography. All successfully treated patients had only one stricture, while all patients with more than one stricture suffered recurrences. Our data also suggest a greater responsiveness for anastomotic strictures than for non-anastomotic strictures. Of the patients with recurrences, five had symptom-free intervals of 23 months or more (up to 31 months). The fact that strictures recurred after such long periods of time underscores the importance of long-term follow-up. In view of the number of patients helped, the favorable experience with post-liver-transplantation strictures, and the lack of any major complications in our series, percutaneous biliary balloon dilatation offers a viable alternative to surgical management of benign biliary strictures.

Primary intrahepatic sclerosing cholangitis with inflammatory bowel disease

A case of primary intrahepatic sclerosing cholangitis associated with inflammatory bowel disease, which is rare in Japan, is reported. A 16-year-old Japanese boy was admitted to our hospital because of abdominal pain and fever. He was diagnosed as having primary intrahepatic sclerosing cholangitis by endoscopic retrograde cholangiography and liver biopsy. Inflammatory bowel disease was diagnosed by colonoscopy and biopsy of the colonic mucosa. Human lymphocyte antigen typing showed HLA-A2, A-9, -B52 and -DR2.

Primary sclerosing cholangitis: a long-term follow-up study

During the 10-year period from 1 January 1975 to 31 December 1984, primary sclerosing cholangitis (PSC) was diagnosed in 45 patients. Twelve of the patients have died (26.7%), 10 of them of causes related to PSC. Inflammatory bowel disease was found in all patients; ulcerative colitis was found in 37, Crohn's disease in 6, and unclassified colitis in 2 patients. Of the patients alive, 27 were submitted to a follow-up study in 1985. At the follow-up examination no general progression of the liver disease, as measured on the basis of clinical examination and levels of transaminases, alkaline phosphatases, and bilirubin, was found. Cholangiographic evaluation in 24 patients showed that the stage of ductal changes progressed from mild to moderate in 3 patients; in the other patients the stage was not altered. Morphologic examination of liver biopsy specimens in patients with a benign clinical course usually showed portal inflammation, fibrosis, and minor signs of piecemeal necrosis, whereas widespread piecemeal necrosis was found in patients who deteriorated and died. The 50% survival since diagnosis of liver disease was calculated to be 17 years in patients with PSC and 50 years in a comparable group among the general population. The estimated survival curve in PSC was displaced to the left, indicating a reduced life expectancy of about 30 years.

Reovirus type 3 infection in patients with primary biliary cirrhosis and primary sclerosing cholangitis

Reovirus type 3 (Reo-3) infection has recently been implicated in the pathogenesis of certain idiopathic, cholestatic liver diseases of newborns. In the present study, antibody titres to Reo-3 virus (anti-Reo-3) were determined in sera from 43 adults with idiopathic cholestatic liver disease, including 34 patients with primary biliary cirrhosis (PBC) and 9 patients with primary sclerosing cholangitis (PSC). Seventy-four adults with various other causes of chronic liver disease and 16 healthy volunteers served as controls. Geometric mean titres of anti-Reo-3 were significantly higher in PBC and PSC sera than chronic liver disease and healthy controls (P less than 0.005). Mean antibody titres for all patient groups, however, were within the 95% confidence limits for normals. Seven of 34 (21%) PBC patients and 3/9 (33%) PSC patients had elevated titres of anti-Reo-3, as compared to only 4/74 (5%) chronic liver disease (P less than 0.05) and 0/16 (0%) healthy control subjects (P less than 0.05) (Fisher's Exact Test). Antibody titres to five other common viruses were normal in patients with high anti-Reo-3 titres when compared to age- and sex-matched controls with liver disease. Immunoperoxidase staining for Reo-3 viral markers and cultures of liver biopsy material for Reo-3 virus were negative in both patients and controls. The results of this study indicate that, although patients with PBC and PSC have higher anti-Reo-3 antibody titres than patients with other forms of chronic liver disease or healthy volunteers, only a minority of these patients have titres that exceed the 95% confidence limits for normals.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk of biliary surgery in patients with hyperbilirubinemia

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.