Oriental cholangiohepatitis (recurrent pyogenic cholangitis): a case series from the Netherlands and brief review of the literature

Oriental cholangiohepatitis is a condition occurring in the Asian population, characterised by recurrent bacterial cholangitis and presence of calculi within the intrahepatic bile ducts, biliary strictures and an increased risk for cholangiocarcinoma. It is an uncommon disease in the West that may not always be considered. The therapeutic approach is multidisciplinary and highly individual, and includes antibiotic therapy, endoscopic and percutaneous biliary drainage with stone removal and dilation of strictures, and in selected cases surgical resection of affected liver segments. We report our experience with five relatively young adult patients largely originating from China, who presented with pyogenic cholangitis and were considered to suffer from oriental cholangiohepatitis. To our knowledge this is the first report of this condition in the Netherlands. Physicians treating patients with pyogenic cholangitis should be aware of this disease and consider the diagnosis in all Asian immigrants with biliary tract disease.

Associating pancreaticostomy and biliary-irrigation for staged pancreaticoduodenectomy approach to pancreatic intraductal papillary mucinous neoplasm with recurrent cholangitis and severe jaundice: A case report

PATIENT CONCERNS

A 63-year-old man was hospitalized with history of abdominal pain since more than 1 year, and that of fever with chills since 2 weeks.

DIAGNOSES

Based on the laboratory investigations and radiologic findings, a preliminary diagnosis of pancreatic intraductal papillary mucinous neoplasm (IPMN) with recurrent cholangitis and severe jaundice was made.

INTERVENTIONS

An initial attempt at endoscopic and image-guided drainage proved unsuccessful. Due to cholangitis, liver dysfunction, and hypoalbuminemia, the patient was deemed to be medically unfit for radical surgery. Therefore we considered a novel strategy of associating pancreaticostomy and biliary-irrigation for staged pancreaticoduodenectomy (APBSP). In the first stage, biliary tract double irrigation (endoscopic nasobiliary drainage and T-tube) in combination with pancreaticostomy was performed, which alleviated the symptoms and helped improve the general condition of the patient. In the second stage, radical pancreaticoduodenectomy was performed.

OUTCOMES

Over a follow-up period of 23 months, no recurrence occurred.

LESSONS

In this report, we present a previously unreported treatment strategy for pancreatic IPMN with recurrent cholangitis and jaundice. The innovative treatment approach may help advance the understanding and management of this condition.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).

Hepatobiliary and pancreatic ascariasis

Hepatobiliary and pancreatic ascariasis (HPA) was described as a clinical entity from Kashmir, India in 1985. HPA is caused by invasion and migration of nematode, Ascaris lumbricoides, in to the biliary tract and pancreatic duct. Patients present with biliary colic, cholangitis, cholecystitis, hepatic abscesses and acute pancreatitis. Ascarides traverse the ducts repeatedly, get trapped and die, leading to formation of hepatolithiasis. HPA is ubiquitous in endemic regions and in Kashmir, one such region, HPA is the etiological factor for 36.7%, 23%, 14.5% and 12.5% of all biliary diseases, acute pancreatitis, liver abscesses and biliary lithiasis respectively. Ultrasonography is an excellent diagnostic tool in visualizing worms in gut lumen and ductal system. The rational treatment for HPA is to give appropriate treatment for clinical syndromes along with effective anthelmintic therapy. Endotherapy in HPA is indicated if patients continue to have symptoms on medical therapy or when worms do not move out of ductal lumen by 3 wk or die within the ducts. The worms can be removed from the ductal system in most of the patients and such patients get regression of symptoms of hepatobiliary and pancreatic disease.

A case report of motesanib-induced biliary sludge formation causing obstructive cholangitis with acute pancreatitis treated by endoscopic sphincterotomy

BACKGROUND

Gallbladder toxicity was reported in most motesanib studies with varying frequency and at variable times after initiation of treatment.

METHOD AND RESULTS

A 44-year-old man was admitted due to severe epigastric pain. The patient was diagnosed with non-small cell lung cancer 9 months ago and received 6 cycles of chemotherapy with motesanib, paclitaxel, and carboplatin. Ultrasonography showed a large amount of sludge within gallbladder. Computed tomography scan demonstrated diffuse dilatation of biliary tree with distended gallbladder without evidence of stone and mild pancreatic swelling. Endoscopic retrograde cholangiopancreatography showed yellowish viscous mucoid plug impacting ampullary orifice and dilated bile duct with amorphous filling defect at distal half of common duct. Endoscopic sphincterotomy was performed to prevent biliary obstruction and recurrent pancreatitis after removal of mucoid material.

CONCLUSION

To the best of our knowledge, this is the first report of obstructive cholangitis and acute pancreatitis associated with sludge formation during motesanib therapy. Endoscopic sphincterotomy appears to be useful to treat and prevent biliary obstruction caused by motesanib-induced biliary sludge.

Familial occurrence of autoimmune liver disease with overlapping features of primary biliary cholangitis and autoimmune hepatitis in a mother and her daughter

We encountered two patients with overlapping features of primary biliary cholangitis and autoimmune hepatitis within the same family. A 68-year-old woman presented at our hospital from a previous medical institution because of the diagnosis of primary biliary cholangitis. Her 49-year-old daughter was admitted with liver dysfunction 4 years later. When compared, these two related patients were found to have overlapping features of primary biliary cholangitis and autoimmune hepatitis. Their human leukocyte antigen haplotype was DRB1*04:05/DRB1*15:02. The clinical and biochemical findings of these two patients immediately improved following treatment with a combination of prednisolone and ursodeoxycholic acid, in accordance with the Japanese guidelines. It is extremely important to identify such pathological conditions as quickly as possible, particularly with the appearance of severe liver dysfunction due to liver cirrhosis, as observed in our case. The Japanese guidelines are considered to be a realistic and useful clinical policy for the swift and efficient treatment of patients with overlapping features of primary biliary cholangitis and autoimmune hepatitis. We suggest that our two patients presented with a genetic predisposition to autoimmune liver disease with overlapping features of primary biliary cholangitis and autoimmune hepatitis within the same family.

Multiple liver abscesses in a dog secondary to the liver fluke Metorchis conjunctus treated by percutaneous transhepatic drainage and alcoholization

A 1-year-old German shepherd × husky cross dog was diagnosed with multiple liver abscesses and severe cholangitis secondary to the liver fluke Metorchis conjunctus. The dog was successfully treated with 2 percutaneous transhepatic drainage and alcoholization procedures, and a prolonged course of antibiotics and praziquantel.

Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis (AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.

Advances in Management of Acute Pancreatitis

This article reviews advances in the management of acute pancreatitis. Medical treatment has been primarily supportive for this diagnosis, and despite extensive research efforts, there are no pharmacologic therapies that improve prognosis. The current mainstay of management, notwithstanding the ongoing debate regarding the volume, fluid type, and rate of administration, is aggressive intravenous fluid resuscitation. Although antibiotics were used consistently for prophylaxis in severe acute pancreatitis to prevent infection, they are no longer used unless infection is documented. Enteral nutrition, especially in patients with severe acute pancreatitis, is considered a cornerstone in management of this disease.

TGR5: pathogenetic role and/or therapeutic target in fibrosing cholangitis?

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease affecting the intrahepatic and extrahepatic biliary tree leading to bile duct strictures, progressive cholestasis, and development of liver fibrosis and cirrhosis. The pathogenesis of PSC is still elusive; however, both an immune-mediated injury of the bile ducts as well as increased recruitment of intestinal-primed T lymphocytes to the biliary tracts seem to contribute to disease development and progression. TGR5 (Gpbar-1) is a G-protein-coupled receptor responsive to bile acids, which is expressed in cholangiocytes, intestinal epithelial cells, and macrophages of the liver and intestine as well as in CD14-positive monocytes of the peripheral blood. Activation of TGR5 in biliary epithelial cells promotes chloride and bicarbonate secretion, triggers cell proliferation, and prevents apoptotic cell death. In immune cells, stimulation of TGR5 inhibits cytokine expression and secretion, thus reducing systemic as well as hepatic and intestinal inflammation. The expression pattern of TGR5 in the liver and intestine as well as the potential protective functions of TGR5 suggest a role for this receptor in the pathogenesis of PSC. While mutations in the coding region of the TGR5 gene are too rare to contribute to overall disease susceptibility, the expression and localization of the receptor have not been studied in PSC livers. Pharmacological activation of TGR5 in mice promotes protective mechanisms in biliary epithelial cells and reduces hepatic and systemic inflammation; however, it also provokes pruritus. Further studies are needed to predict the potential benefits as well as side effects of TGR5 agonist treatment in PSC patients.

Risk factors of organ failure in cholangitis with bacteriobilia

AIM: To identify the risk factors for organ failure (OF) in cholangitis with bacteriobilia.

METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.

RESULTS: There were 24 cases (13.2%) of OF and five deaths (2.7%). Bile culture was positive for microbial growth in 130 out of 138 (94.2%) patients. In multivariate analysis of 130 patients with positive bile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase (ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation: (2.7 × ESBL organisms in blood cultures) + (1.8 × pre-existing renal dysfunction) + (1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific (99.1%) and had a positive predictive value of 86.2%.

CONCLUSION: ESBL organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.

Thrombomodulin in the management of acute cholangitis-induced disseminated intravascular coagulation

AIM: To evaluate the need for thrombomodulin (rTM) therapy for disseminated intravascular coagulation (DIC) in patients with acute cholangitis (AC)-induced DIC.

METHODS: Sixty-six patients who were diagnosed with AC-induced DIC and who were treated at our hospital were enrolled in this study. The diagnoses of AC and DIC were made based on the 2013 Tokyo Guidelines and the DIC diagnostic criteria as defined by the Japanese Association for Acute Medicine, respectively. Thirty consecutive patients who were treated with rTM between April 2010 and September 2013 (rTM group) were compared to 36 patients who were treated without rTM (before the introduction of rTM therapy at our hospital) between January 2005 and January 2010 (control group). The two groups were compared in terms of patient characteristics at the time of DIC diagnosis (including age, sex, primary disease, severity of cholangitis, DIC score, biliary drainage, and anti-DIC drugs), the DIC resolution rate, DIC score, the systemic inflammatory response syndrome (SIRS) score, hematological values, and outcomes. Using logistic regression analysis based on multivariate analyses, we also examined factors that contributed to persistent DIC.

RESULTS: There were no differences between the rTM group and the control group in terms of the patients’ backgrounds other than administration. DIC resolution rates on day 9 were higher in the rTM group than in the control group (83.3% vs 52.8%, P < 0.01). The mean DIC scores on day 7 were lower in the rTM group than in the control group (2.1 ± 2.1 vs 3.5 ± 2.3, P = 0.02). The mean SIRS scores on day 3 were significantly lower in the rTM group than in the control group (1.1 ± 1.1 vs 1.8 ± 1.1, P = 0.03). Mortality on day 28 was 13.3% in the rTM group and 27.8% in the control group; these rates were not significantly different (P = 0.26). Multivariate analysis identified only the absence of biliary drainage as significantly associated with persistent DIC (P < 0.01, OR = 12, 95%CI: 2.3-60). Although the difference did not reach statistical significance, primary diseases (malignancies) (P = 0.055, OR = 3.9, 95%CI: 0.97-16) and the non-use of rTM had a tendency to be associated with persistent DIC (P = 0.08, OR = 4.3, 95%CI: 0.84-22).

CONCLUSION: The add-on effects of rTM are anticipated in the treatment of AC-induced DIC, although biliary drainage for AC remains crucial.

Severe Acute Cholangitis with Complications of Bacterial Meningitis Associated with Hearing Loss

We herein report a case of severe acute cholangitis complicated by bacterial meningitis. A 56-year-old Japanese man was admitted to our hospital due to a consciousness disorder that had developed while he was being treated for acute cholangitis. The levels of both hepatobiliary enzymes and inflammatory markers were high, and computed tomography revealed common bile duct stones and cholangiectasis. A diagnosis of acute cholangitis was made, and meningitis was subsequently confirmed on a cerebrospinal fluid analysis. The patient recovered successfully after receiving emergency endoscopic drainage and antibiotic therapy. This case demonstrates that a disturbance of consciousness complicated by acute cholangitis may result from septic encephalopathy as well as meningitis via bloodstream infections.

IgG4-related cholangitis: Case report and literature review

CASE PRESENTATION

We describe a case of a patient who presents with jaundice, elevated cholestatic liver enzymes, an extreme weight loss and a midcholedochal stricture very suspect for a cholangiocarcinoma. In the conviction of malignancy, although the absence of anatomopathological prove, the patient underwent a choledochal resection. The anatomopathological specimen revealed no malignancy. In the year following resection, the patient keeps presenting with bile duct strictures and further weight loss. Ultimately the diagnosis of Ig G4-related cholangitis is withheld. Therapy with corticosteroids is initiated with a spectacular clinical, biochemical and radiographical result.

DISCUSSION

IgG4-related cholangitis is the biliary presentation of IgG4-related disease, a recently discovered entity of fibroinflammatory masses which can affect virtually every organ in the body. It is characterized by a dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis and a presence of > 30 IgG4-positive plasma cells per high power field. Main differential diagnosis contains cholangiocarcinoma and primary sclerosing cholangitis. Corticoids are cornerstone of therapy, with azathioprine frequently used as a maintenance in case of relapse.

CONCLUSIONS

With this case we want to draw the attention to a rather uncommon cause of biliary obstruction, easily mistaken for a cholangiocarcinoma.

Biliary cast - complication of cholangitis and pancreatitis in a pancreas divisum patient

We report a rare cause of biliary cast secondary to cholangitis and pancreatitis, in a 60 year old female patient with pancreas divisum. She was admitted in our hospital with an acute pancreatitis (alcoholic etiology was excluded) complicated with pancreatic abscess and obstructive jaundice. The patient had undergone a complex surgical intervention: cholecystectomy,choledocotomy with extraction of the biliary thrombus,external biliary drainage through a T tube, evacuation of the pancreatic abscess, sequestrectomy, peritoneal lavage and multipledrainages. In spite of the surgical and intensive care support,the biliary drainage through the T tube had ceased and the obstructive jaundice had reappeared in a more accentuated fashion. Endoscopic retrograde cholangiography showed complete pancreas divisum and diffuse multiple stenosis alternating with dilatation of the intrahepatic biliary tree (a pattern of sclerosing cholangitis). An endoscopic prosthesis was placed inside the right hepatic bile duct. Despite the use of the combined endoscopic plus UDCA (ursodeoxycholic acid) treatment for the management of the biliary cast syndrome, the evolution was unfavorable with hepatic coma,septic shock and finally death. The necropsy revealed an extensive biliary cast in the entire biliary tree and pyogeniccholangitis. The patient had a fatal outcome despite all the surgical, endoscopic and conservative efforts, with development of intraductal biliary obstruction and secondary pyogenic cholangitis. Biliary cast syndrome is a rare but very aggressive entity and its management is often difficult despite the advances in surgery and endoscopy treatments.

Lemmel's syndrome, an unusual cause of abdominal pain and jaundice by impacted intradiverticular enterolith: case report

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.

[The ways of prophylaxis of the pancreatic injuries occurring on background of cholangitis and choledocholithiasis complicated by obturation jaundice: algorithm for diagnosis and treatment]

The results of treatment of 45 patients, in whom obturation jaundice have occurred on background of purulent cholangitis and biliary calculous disease, were summarized. preoperatively conservative therapy was conducted to the patients, including ozonotherapy during 9 - 10 days (main group) and 2 - 4 days (control group). All the patients were operated on. Conservative therapy, conducted during 9 -- 10 days, have permitted to improve clinical and laboratory indices more rapidly postoperatively, to prognosticate possibilities of the pancreatic gland damage, pancreatitis occurrence, as well as its exacerbation in future.

Septic ketoacidosis

Various unmeasured anions other than lactate appear in the blood of septic patients, including ketones. However, the occurrence of sepsis-induced ketoacidosis without diabetes mellitus has not been reported to date. We herein describe severe ketoacidosis in a patient with septic shock despite the absence of diabetes, alcohol and starvation. A 76-year-old woman presented with septic shock due to acute obstructive cholangitis. She exhibited ketoacidosis and a remarkably strong ion gap, except for ketones. Sepsis alone may lead to ketoacidosis in patients without diabetes under specific conditions. The accumulation of ketones and other strong anions can occur in cases involving a decreased metabolic function. There may be a pathological condition called septic ketoacidosis.

IgA-dominant postinfectious glomerulonephritis associated with Escherichia coli infection caused by cholangitis

A 76-year-old man with a history of type 2 diabetes mellitus was admitted with cholangitis caused by cholangiocarcinoma. Cholangitis with Escherichia coli (E. coli) bacteremia recurred due to the unstable bile drainage. At 1 month after recurrence, rapidly progressive glomerulonephritis with nephrotic syndrome was manifested. Renal biopsy findings were consistent with immunoglobulin A (IgA)-dominant postinfectious glomerulonephritis (PIGN). After ensuring that the recurrent cholangitis was controlled by drainage and antibiotic therapy, oral prednisolone was initiated, and the patient's renal function and proteinuria subsequently gradually improved. This is the first case report of IgA-dominant PIGN associated with cholangitis caused by E. coli infection.

Clinical impact of preoperative cholangitis after biliary drainage in patients who undergo pancreaticoduodenectomy on postoperative pancreatic fistula

The objective of this study was to examine whether the development of cholangitis after preoperative biliary drainage (PBD) can increase the incidence of postoperative pancreatic fistula (POPF). The study population included 185 consecutive patients who underwent pancreaticoduodenectomy from April 2006 to March 2011. All patients were divided into two groups, which consisted of a "no PBD" group (73 patients) and a PBD group (112 patients). Moreover, the PBD group was divided into a "cholangitis" group (21 patients) and a "no cholangitis" group (91 patients). Clinical background, clinical outcome, and postoperative complications were compared between groups. All patients received prophylactic antibiotics using cefmetazole until 1 or 2 days postoperatively. There was no difference between noncholangitis and non-PBD groups except the frequency of overall POPF. Clinically relevant POPF and drain infection occurred in the cholangitis group significantly more than in the noncholangitis group (P < 0.05). Univariate and multivariate analyses showed that development of preoperative cholangitis after preoperative biliary drainage and small pancreatic duct (less than 3 mm diameter) were independent risk factors for clinically relevant POPF. The frequency of clinically relevant POPF was 8 per cent (eight of 99) in patients without two risk factors, 19 per cent (15 of 80) in patients with one risk factor, and 50 per cent (three of six) in patients with both risk factors. The development of preoperative cholangitis after PBD was closely associated with the development of clinically relevant POPF under the limited use of prophylactic antibiotics.