The significance of biliary pressure in cholangitis

Risk factors for cefmetazole-non-susceptible bacteremia in acute cholangitis

INTRODUCTION

Cefmetazole (CMZ), an antibiotic with limited international distribution, is recommended by the Tokyo Guidelines 2018 (TG18) for non-severe cases of acute cholangitis (AC). However, the risk factors for CMZ-non-susceptible (CMZ-NS) bacteremia in AC remain unclear. Here, we aimed to investigate the risk factors for CMZ-NS bacteremia and evaluate mortality in patients with AC.

METHODS

This single-center, retrospective, observational study included all patients diagnosed with definite bacteremic AC, based on TG18, from April 2019 to March 2023. Risk factors for CMZ-NS bacteremia were analyzed by univariate, and age- and sex-adjusted, logistic regression analyses. Mortality was compared by cause of obstruction, CMZ-susceptible/CMZ-NS bacteremia, and initial treatment.

RESULTS

In total, 165 patients were enrolled. CMZ-NS bacteremia was diagnosed in 46 (27.9 %) patients. Histories of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy were identified as significant factors associated with the risk of CMZ-NS bacteremia. Thirteen patients died within 30 days of hospital admission. The mortality of patients with AC and malignant biliary obstruction was statistically higher than that of patients with bile duct stones. No patients with AC and bile duct stones died in the group with CMZ-NS bacteremia and inappropriate initial antibiotics.

CONCLUSIONS

In AC, a history of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy are associated with an increased risk of CMZ-NS bacteremia. Therefore, the choice of empiric therapy for AC should be based on the etiology and patient background, rather than on the severity.

The role of procalcitonin as a prognostic factor for acute cholangitis and infections in acute pancreatitis: a prospective cohort study from a European single center

BACKGROUND

Infection in acute pancreatitis will worsen the disease prognosis. The aim of our study was to analyze the role of procalcitonin as a prognostic biomarker for infections and clinical severity.

METHOD

A prospective single-cohort observational study of patients diagnosed of acute pancreatitis (n = 152) was designed. PCT determination was tested on admission (first 72 h). Infections (biliary, extrapancreatic and infected pancreatic necrosis), need for antibiotics, urgent ERCP and severity scores for acute pancreatitis was assessed. ROC curves were designed and the area under the curve was calculated. Logistic regression for multivariate analysis was performed to evaluate the association between procalcitonin optimal cut-off level and major complications.

RESULTS

PCT >0.68 mg/dL had higher incidence of global infection, acute cholangitis, bacteraemia, infected pancreatic necrosis, use of antibiotics in general, and need for urgent ERCP. In the multivariate regressions analysis, PCT >0.68 mg/dL at admission demonstrated to be a strong risk factor for complications in acute pancreatitis.

DISCUSSION

PCT levels can be used as a reliable laboratory test to predict infections and the clinical severity of acute pancreatitis. High levels of PCT predict antibiotics prescription as well as the need for urgent ERCP in patients with concomitant clinically severe cholangitis.

Severe Acute Cholangitis and Bacteremia Due to Campylobacter jejuni: A Case Report and Review of the Literature

Campylobacter jejuni is common cause of enteritis, but biliary infection rarely reported. An 82-year-old woman with pancreatic head cancer underwent endoscopic biliary drainage for malignant biliary obstruction. She was subsequently admitted for management of diarrhea. C. jejuni was identified in stool culture. Her symptoms resolved temporarily without antibiotics but flared up with a fever a few days later. She was diagnosed with acute cholangitis and bacteremia with C. jejuni. Endoscopic biliary drainage and antimicrobial administration improved her symptoms. As complications of C. jejuni diarrhea are rare, antibiotics are not necessarily indicated but sometimes are needed to prevent complications.

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.

ACR Appropriateness Criteria® Radiologic Management of Biliary Obstruction

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The role of Intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy

AIM

Liver transplantation remains the only curative treatment in end stage liver disease. Biliary complications remain the most common major morbidity causes in hepatic resection. We aimed to determine and eliminate the bile leakage in donor hepatectomy of LDLT.

MATERIAL AND METHODS

This study was conducted retrospective and one center study. The study population included 110 consequential liver donors with major liver resection (more than three segments). The population was divided into three groups for data analyses. Primary study groups included 40 donors subjected to methylene blue test starting in April 2013 and 40 donors subjected to intraoperative cholangiography started in March 2014.

RESULTS

A total of 110 liver donors (42.7% women) were included in the study. Postoperative biliary complications were less in methylene blue and intraoperative cholangiography (IOC) groups. Bile leakage was significantly higher in control group (23.3%) compared to methylene blue (5%) and IOC groups (2%) Average duration of hospital stay and duration of operation were significantly higher in control group compared to methylene blue and IOC groups.

CONCLUSION

In our study we conducted to establish biliary leakage in living donor hepatectomy which intraoperative cholangiography test was used to determine. Many intraoperative methods have been introduced to prevent biliary leakage and development of complications. We have showed that IOC test used in the present study could be easily applied in both living liver donor hepatectomy and other major hepatectomy cases. IOC test reduced postoperative biliary leakage incidence and did not increase incidence of other complications.

Use of aerosol protective barrier in a patient with impending cholangitis and unknown COVID-19 status undergoing emergency ERCP during COVID-19 pandemic

WHO declared worldwide outbreak of COVID-19 a pandemic on 11 March 2020. Healthcare authorities have temporarily stopped all elective surgical and endoscopy procedures. Nevertheless, there is a subset of patients who require emergency treatment such as aerosol-generating procedures. Herein, we would like to discuss the management of a patient diagnosed with impending biliary sepsis during COVID-19 outbreak. The highlight of the discussion is mainly concerning the advantages of concurrent use of aerosol protective barrier in addition to personal protective equipment practice, necessary precautions to be taken during endoscopy retrograde cholangiopancreatography and handling of the patient preprocedure and postprocedure.

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.

Pyogenic liver abscess related to intrahepatic bile duct stones: Difficulties in infectious control and diagnosis of concomitant cholangiocarcinoma

BACKGROUND AND AIM

Cholangitis, bacteremia, and pyogenic liver abscess (PLA) can be often caused by intrahepatic bile ducts stone (IBDS), which is endemic to South-East Asia. The association between IBDS and cholangiocarcinoma has been well recognized. Concomitant cholangiocarcinoma in the PLA related to IBDS is often missed.

METHODS

A case-control study consisting of 64 patients with PLA related to IBDS and 256 control patients with PLA not related to IBDS was used to investigate clinical features of PLA and incidence of concomitant cholangiocarcinoma in patients with PLA related to IBDS.

RESULTS

The main imaging manifestations of PLA related to IBDS was cystic-solid lesions and solid lesions. Of seven patients (10.9%) with pathology-proven cholangiocarcinoma in the same area of PLA related to IBDS among 64 patients, only two patients were initially diagnosed as having concomitant cholangiocarcinoma by biopsy, and other five patients diagnosed as acute inflammatory lesion. Within 60 days after onset, the infection-related death rate and recurrence rate in patients with PLA related to IBDS were 12.9% and 20.3%, respectively, whereas in patients with PLA not related to IBDS were 3.9% and 3.1%, respectively. Only 25% of patients with PLA related to IBDS underwent surgery after admission. The main pathogens in PLA patients related to IBDS were Escherichia coli and extended-spectrum beta-lactamase-producing Enterobacteriaceae.

CONCLUSIONS

The imaging manifestations of PLA related to IBDS often present cystic-solid or solid lesions. PLA related to IBDS is characterized by high rate of recurrence and infection-related death, difficulty in diagnosis of concomitant cholangicarcinoma.

The utility of 5-aminolevulinic acid-mediated photodynamic diagnosis in the detection of intraoperative bile leakage

PURPOSE

The purpose of this retrospective study was to evaluate the utility of the new intraoperative bile leakage test as a preventive measure of postoperative bile leakage.

METHOD

737 patients were retrospectively analyzed with respect to the management of intra- and post-operative bile leakage.

RESULTS

Nine (8.3%) of 109 patients evaluated using conventional white light fluorescent imaging were recognized as having intra-operative bile leakage. However, performance of 5-aminolevulinic acid (5-ALA)-mediated PDD detected bile leakage intraoperatively not only in these 9 patients, but also in an additional 6 patients, such that 'red fluorescence' at the cut surface of the liver, was visualized in a total of 15 patients. The postoperative courses of most patients were uneventful, and postoperative bile leakages occurred in only one (0.9%) patient.

CONCLUSION

5-ALA fluorescence imaging may be needed to prevent postoperative bile leakage in patients at high risk for this surgical complication after hepatic resection.

Acute Bacterial Cholangitis

Background

Acute bacterial cholangitis for the most part owing to common bile duct stones is common in gastroenterology practice and represents a potentially life-threatening condition often characterized by fever, abdominal pain, and jaundice (Charcot's triad) as well as confusion and septic shock (Reynolds' pentad).

Methods

This review is based on a systematic literature review in PubMed with the search items ‘cholangitis’, ‘choledocholithiasis’, ‘gallstone disease’, ‘biliary infection’, and ‘biliary sepsis’.

Results

Although most patients respond to empiric broad-spectrum antibiotic treatment, timely endoscopic biliary drainage depending on the severity of the disease is required to eliminate the underlying obstruction. Specific recommendations have been derived from the Tokyo guideline working group consensus 2006 and its update in 2013, albeit poorly evidence-based, providing a comprehensive overview of diagnosis, classification, risk stratification, and treatment algorithms in acute bacterial cholangitis.

Conclusion

Prompt clinical recognition and accurate diagnostic workup including adequate laboratory assessment and (aetiology-oriented) imaging are critical steps in the management of cholangitis. Treatment is directed at the two major interrelated pathophysiologic components, i.e. bacterial infection (immediate antimicrobial therapy) and bile duct obstruction (biliary drainage). As for the latter, transpapillary endoscopic drainage by stent or nasobiliary drain and/or same-session bile duct clearance, depending on individual disease severity, represent first-line treatment approaches.

How to interpret the bile culture results of patients with biliary tract infections

BACKGROUND/GOALS

Bile is normally sterile, but the presence of organisms in the bile does not necessarily imply an active infection. We wonder what the significance of bile culture results on antibiotics choice in cholangitis with negative blood culture. The aim of this study was to compare organisms cultured from bile with those from blood in bacteremic biliary tract infection and to evaluate factors associated with concordance between blood and bile isolates.

METHODS

Between 2000 and 2010, 266 positive blood cultures with concomitant bile culture in bacteremic biliary tract infection were identified. Follow-up bile specimens obtained after negative conversion of blood culture and clinical recovery from acute infection were collected for supplementary analysis.

RESULTS

Of the 266 events, 258 showed positive bile culture. Of the 258 bile samples, 80 yielded the same organisms with blood, 129 showed partial agreement and 49 yielded completely different organisms with blood. Only the number of organism was found to be independently associated with concordance. Of the 529 organisms isolated from bile, 227 were found in blood and gram-negative organisms showed higher rate of coincidence than gram-positive organisms. Of the 84 follow-up bile sample, 94% showed persistent positive culture and higher rate of antibiotics resistance than initial bile culture.

CONCLUSIONS

More than half of the organisms isolated from bile, especially gram-positive organisms, are not likely to be true pathogens. But single organism cultured from bile has clinical significance. Routine follow-up bile culture in patients showing clinical improvement is not necessary.

Bile leakage test in liver resection: A systematic review and meta-analysis

AIM: To assess systematically the safety and efficacy of bile leakage test in liver resection.

METHODS: Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search. Two authors independently assessed the studies for inclusion and extracted the data. A meta-analysis was conducted to estimate postoperative bile leakage, intraoperative positive bile leakage, and complications. We used either the fixed-effects or random-effects model.

RESULTS: Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection. The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group (RR = 0.39, 95%CI: 0.23-0.67; I² = 3%). The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test (RR = 2.38, 95%CI: 1.24-4.56, P = 0.009). No significant intergroup differences were observed in total number of complications, ileus, liver failure, intraperitoneal hemorrhage, pulmonary disorder, abdominal infection, and wound infection.

CONCLUSION: The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications. Fat emulsion is the best choice of solution for the test.

Emergency endoscopic retrograde cholangiopancreatography in critically ill patients is a safe and effective procedure

Emergency ERCP may be required in patients with severe cholangitis who rapidly deteriorate with multi-organ dysfunction and who cannot wait until the next available elective list. A significant proportion of patients require ventilatory and inotropic support. We describe our experience on the outcome of emergency ERCP in this cohort of critically ill patients. Medical records of cases undergoing ERCP between November 2008 and November 2011 were retrospectively reviewed. Patients who were in intensive care unit or required general anaesthesia due to haemodynamic compromise at the time of ERCP were included. Total of 2237 ERCPs were performed during this period, of which 36 (2%) emergency ERCP's were performed in 33 patients. The median age was 79 years. All procedures were performed under general anaesthesia in emergency operating room. In 27/36 procedures (75%), the patients required inotropes. Indications included cholangitis (78%), pancreatitis (14%) and post-operative bile leak (8%). Biliary cannulation was achieved in 100% of cases. Endoscopic findings included CBD stones (64%), CBD stones and an additional pathology (8%), bile leak (8%), CBD stricture (5%), Mirizzi's (3%) and blocked plastic stent (3%). In 23/36 (64%) procedures a stent was inserted. In 11/36 (30%) procedures a balloon trawl was sufficient to clear the bile duct. Thirty-day mortality was 25%. Although the 30-day mortality remains high due to multi-organ failure, ERCP is successful and effective in the majority of patients and results in a good outcome for this cohort of critically ill patients, in whom the prognosis is inevitably poor without emergency biliary drainage.

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.

Effects of plastic stenting in commom bile duct of rats: a quantitative reaction analysis using collagen and elastin morphometry

PURPOSE: To evaluate the effects of biliary stenting in rats through analysis of collagen and elastin deposition in the bile ducts. METHODS: Twenty male rats underwent midline laparotomy, duodenotomy and transampullary stenting of the common bile duct with a 22Fr plastic stent. Animals were randomized in 4 groups, with 5 components in each: (I) control, (II) biliary stenting for 7 days, (III) biliary stenting for 14 days, and (IV) biliary stenting for 30 days. Sections of the common bile duct were stained using Hematoxylin Eosin; Sirius Red to quantitate the amount of collagen present; and Weigert's Resorcin-fuchsin to quantitate the amount of elastin present. RESULTS: The percentage of area stained for collagen was 13.4; 21.5; 29.5 and 32.8, for groups I to IV, respectively. The percentage of area stained for elastin fibers was 7.0; 5.2; 4.0 and 2.9, for groups I to IV, respectively. Collagen/Elastin ratio was 2.4; 5.1; 11.0 and 14.4 for groups I to IV, respectively. CONCLUSIONS: The biliary stenting leads to collagen and elastin deposition in the bile ducts; and collagen deposition and collagen/elastin ratio are proportional to the period of stenting.

Diagnosis and management of acute cholangitis

Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.

Management of ascending cholangitis

Acute ascending cholangitis is a potential life-threatening emergency characterized by infection and obstruction of the biliary tree. This article reviews the pathogenesis and clinical approach to patients with ascending cholangitis and examines the literature on this topic.

Sonographic demonstration of duodenobiliary reflux with soda enhancement

Cholangitis rarely occurs after sphincteroplasty if there is no biliary obstruction. We report the case of a patient who developed recurrent cholangitis despite having a patent biliary tract after sphincteroplasty. Duodenobiliary reflux was demonstrated on sonography after enhancement of the reflux flow with a novel oral contrast agent, a carbonated soda beverage. Sonography with contrast enhancement provided by soda solution may prove satisfactory to detect duodenobiliary reflux after sphincteroplasty safely, effectively, and economically.

Cholangitis: bacterial virulence factors that facilitate cholangiovenous reflux and tumor necrosis factor-alpha production

In previous studies we noted that biliary bacteria produce slime and possess P1-fimbriae. The presence of gram-negative bacteria killed by complement correlated with serious biliary infections and induced more tumor necrosis factor-alpha (TNF-alpha) production in sera, suggesting a role for cytokine production and complement activation in biliary sepsis. This study examined bacterial virulence factors that facilitate cholangiovenous reflux (CVR) and TNF-alpha production in a rat model. Twenty-one biliary bacteria and two stool isolates were tested for slime production, sensitivity to complement killing, and hemolysin production. 10(7) Bacterial colony-forming units/ml (or saline control) were injected retrograde into the common bile ducts of Sprague-Dawley rats at a pressure of 30 cm H(2)O. Blood was obtained at 5 and 60 minutes after infusion for bacterial culture and TNF-alpha assay, respectively. The magnitude of slime production correlated inversely with the magnitude of bacterial CVR. Average bacterial colony-forming units were 1.4 x 10(5), 6.8 x 10(4), or 2.1 x 10(3) for bacteria with slime production 0 to 10, 11 to 99, or more than 100, respectively (P < 0.0001, analysis of variance). CVR was greater for serum-resistant bacteria (1.2 x 10(5) vs. 5.5 x 10(4) [P = 0.007, resistant vs. sensitive]), but TNF-alpha production was greater in serum-sensitive bacteria. TNF-alpha production as a function of bacterial reflux followed a logarithmic curve (R(2) = 0.75) for serum-sensitive bacteria but was linear (R(2) = 0.60) for serum-resistant bacteria. These data show how specific virulence factors explain why some bacterial species colonize without causing illness, whereas others colonize and cause sepsis. Although slime production was necessary for colonization, too much slime inhibited CVR. Although complement killing cleared bacteria from the circulation, it was also associated with increased TNF-alpha production, which can lead to septic manifestations. The most virulent bacterial species (from patients with sepsis) were killed by complement, but they still had significant CVR and were associated with increased TNF-alpha production.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

The effects of bile duct obstruction on the biliary secretion of ciprofloxacin in piglets

OBJECTIVE

The aim of this study was to evaluate the effect of bile duct obstruction on biliary secretion of ciprofloxacin and to look for useful parameters to guide clinical use of antibiotics in patients with acute cholangitis.

METHODS

Twenty-five Landrace piglets were used in this study. Their common bile ducts were ligated, with a duration ranging from 1 to 7 days. The changes of liver biochemical tests, intrabiliary pressure, diameter of common bile duct, and concentration of ciprofloxacin in bile were compared among the piglets with different severity of bile duct obstruction.

RESULTS

The bile-to-serum ratio of the ciprofloxacin concentration was 586.4% +/- 140.3% before the ligation of bile duct and was reduced significantly to 94.5% +/- 118.0% after 1-day obstruction. The biliary secretion of ciprofloxacin was greatly affected by the intrabiliary pressure in that the bile-to-serum ratio of ciprofloxacin concentration was reduced to 12.2% +/- 14.8% when the intrabiliary pressure reached to 32 cm H2O. The change in the intrabiliary pressure was correlated with the diameter of common bile duct, with a correlation coefficient of 0.90 (p < 0.001).

CONCLUSIONS

Biliary secretion of ciprofloxacin is decreased in proportion to the increase of intrabiliary pressure. In obstruction, a markedly dilated common bile duct usually indicates high intrabiliary pressure, and thus biliary concentrations of antibiotics will be lower than expected. Hence, our observations suggest that choosing an antibiotic with high antimicrobial activity, or establishing a biliary drainage to lower the intrabiliary pressure, would be beneficial for patients suffering from cholangitis with a dilated biliary tree.

Bacterial translocation from the biliary tract to blood and lymph in rats with obstructive jaundice

BACKGROUND

The disruption of the hepatocyte tight junctions observed in biliary obstruction suggests altered permeability of the blood-bile barrier. In this study the role of biliary obstruction and increased biliary pressure on the translocation of bacteria from biliary tract to bloodstream and lymphatic system were evaluated.

MATERIALS AND METHODS

Rats underwent distal bile duct ligation (BDL, n = 33) for two weeks or a sham celiotomy (n = 21). Seventeen of the 33 BDL rats underwent subsequent biliary decompression by a choledochojejunostomy (CJ). Two weeks after the final operation, a laparotomy was performed again and the CBD, the thoracic duct, and the caval vein were canulated. Next, a suspension containing 10(8) Escherichia coli/ml was retrogradely infused in the CBD for 5 min at 5 or 20 cm H2O above the secretory biliary pressure.

RESULTS

A higher biliary infusion pressure resulted in a significant increase of cfu E.coli per milliliter of blood in all the three groups (Sham, BDL, CJ). BDL rats showed significantly more bacterial translocation to the bloodstream than the shams. After biliary decompression, translocation normalized to the control levels. At 5 cm H2O infusion pressure only one lymph culture was positive (CJ group). At 20 cm H2O overpressure, nine lymph cultures were E.coli positive (P = 0.03). These were found mainly in groups with a nonobstructed bile duct (Sham and CJ 40% vs BDL 10%).

CONCLUSION

Translocation of bacteria from biliary tract to bloodstream increased at higher intrabiliary pressures. Longstanding bile duct obstruction was an independent determinant for cholangiovenous reflux. Bacterial translocation to the lymphatic system did not parallel translocation to the bloodstream, although in the nonobstructed biliary tract, increased bacterial translocation to the lymphatic system was pressure related.

Biliary infection

Biliary infections are common conditions that can be life threatening. In the past, many of these conditions mandated emergency surgery, but advances in endoscopic and radiological techniques have allowed some of these to be managed in a minimally invasive fashion. Acute cholangitis is caused by infection in an obstructed biliary tree. Endoscopic drainage, together with broad-spectrum antibiotics, has replaced emergency common duct exploration and T-tube drainage as standard treatment. Oriental cholangitis, sclerosing cholangitis and AIDS-related cholangitis are some of the variants of cholangitis. Pyogenic liver abscesses complicating cholangitis can be managed by radiological percutaneous drainage. Close collaboration between surgeons, endoscopists and radiologists is the key to success in managing biliary infections.

Endoscopic drainage aborts endotoxaemia in acute cholangitis

Forty patients with acute calculous cholangitis had successful endoscopic drainage. Bile from nasobiliary drains and venous blood was collected at 0, 12, 24, 36 and 48 h after endoscopy. Endotoxin levels were measured by the chromogenic Limulus Amoebocyte Lysate assay. There was a significant reduction in both bile and serum endotoxin levels after endoscopic drainage (P < 0.001). Endotoxaemia occurred when bile endotoxin reached 10(3) EU/ml and rose exponentially beyond this threshold. Significant association was demonstrated between both bile and serum endotoxins to the clinical features of cholangitis (P < 0.05). No correlation was evident between serum endotoxin and the parameters of white cell count, serum bilirubin and alkaline phosphatase (r = 0.53, 0.00 and 0.00 respectively). Endoscopic drainage is effective in lowering bile and serum endotoxin levels and clinical signs and symptoms reliably predict endotoxaemia.

Biliary IgA secretion in obstructive jaundice: the effects of endoscopic drainage

BACKGROUND

Immunoglobulin A is the predominant immunoglobulin in the bile. Data on the effects of biliary obstruction on IgA secretion are few.

METHODS

The serum and bile IgA levels in patients with common duct stones (n = 27) or with malignant obstructive jaundice (n = 20) were collected by insertion of nasobiliary catheters. Single samples of common duct bile from patients with gallstones (n = 24) were collected as controls. Bile samples collected were measured for total IgA, secretory IgA, and free secretory component levels by sandwich enzyme-linked immunosorbent assays.

RESULTS

Bile total IgA, secretory IgA, and free secretory component in the common duct stones group (82.7 +/- 11.4 microgram/ml, 18.4 +/- 1.7 microgram/ml, 0.74 +/- 0.15 microgram/ml) and the malignant obstructive jaundice group (81.6 +/- 10.7 microgram/ml, 18.2 +/- 2.4 microgram/ml, 0.57 +2- 0.12 microgram/ml) were found to be significantly lower than those of the control gallstone patients (104.8 +/- 3.4 microgram/ml, 33.2 +/- 2.9 microgram/ml, 1.03 +/- 0.12 microgram/ml) (P < 0.05). Serum secretory IgA levels in the common duct stones (26.53 +/- 1.75 microgram/ml) and malignant obstructive jaundice groups (26.03 +/- 3.48 microgram/ml) were significantly higher than the gallstone group (18.45 +/- 4.56 microgram/ml). The bile-to-serum concentration ratio of total IgA, secretory IgA, and free secretory component levels rose significantly within 48 hours after relief of obstruction.

CONCLUSIONS

Biliary obstruction secondary to both calculus or malignancy of the hepatobiliary system causes suppression of bile IgA secretion and elevated serum level of secretory IgA. Bile secretory IgA secretion recovers with endoscopic drainage of the obstructed system.

Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis

Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

Emergency endoscopic nasobiliary drainage for acute calculous suppurative cholangitis and its potential use in chemical dissolution

Acute suppurative cholangitis is one of the common causes of acute abdomen in Taiwan. Emergency decompression is a life-saving procedure if patients fail to respond to antibiotic treatment. From July 1988 to June 1991, 224 patients were encountered with concomitant bile duct stones and cholangitis; 40 were brought to the emergency service with shock or mental confusion or responded poorly to antibiotic treatment. The patients consisted of 20 males and 20 females aged 21-81 years (mean age 64 years); 55% had intrahepatic duct stones, 50% had positive blood culture, 38% had undergone previous biliary surgery, 25% had concomitant medical illnesses and 20% presented with mental confusion. Emergent endoscopic nasobiliary drainage (ENBD) was performed within 48 h of each patient's arrival in the emergency room. In 3 days all the patients exhibited significant improvement as defined by body temperature, vital signs, white blood cell count, serum bilirubin and alkaline phosphates levels. When their condition had stabilized, 21 patients underwent elective surgery. Six patients received ethylenediaminetetraacetic acid infusion through an ENBD tube. Two of the patients' stones dissolved completely. Six patients received papillotomy with stone removal. The remaining patients refused further treatment. There was no hospital mortality. It is therefore concluded that ENBD offers an effective treatment for acute calculus suppurative cholangitis and it is a potential route of administration for the chemical dissolution of bile duct stones.

Defense system in the biliary tract against bacterial infection

Bacteria can invade the biliary tract by ascending from the duodenum and via the hematogenous route from the hepatic portal venous blood. The sphincter of Oddi, situated at the junction of the biliary tract and the upper gastrointestinal tract, forms an effective mechanical barrier to duodenal reflex and ascending bacterial infection. Conversely, Kupffer cells and the tight junctions between hepatocytes help prevent bacteria and toxic metabolites from entering the hepatobiliary system from the portal circulation. The continuous flushing action of bile and the bacteriostatic effects of bile salts keeps the biliary tract sterile under normal conditions. Secretory immunoglobulin A (sIgA), the predominant immunoglobulin in the bile, and mucus excreted by the biliary epithelium probably function as antiadherence factors, preventing microbial colonization. When barrier mechanisms break down, as in surgical or endoscopic sphincterotomy and with insertion of biliary stents, pathogenic bacteria enter the biliary system at high concentrations and take up residence on any foreign bodies. Intrabiliary pressure is a key factor in the development of cholangitis. Chronic biliary obstruction raises the intrabiliary pressure. This adversely influences the defensive mechanisms such as the tight junctions, Kupffer cell functions, bile flow, and sIgA production in the system, resulting in a higher incidence of septicemia and endotoxemia in these patients. Knowledge of biliary defense against infection is still quite primitive. Unclear are the roles of sIgA in the bile, mechanism of bacterial adhesion to the biliary epithelium, Kupffer cell function in biliary obstruction, and the antimicrobial activity of bile salts.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Acute cholangitis

Cholangitis is an infection of the biliary ductal system that results from the combination of bactibilia and biliary obstruction. Choledocholithiasis has been the leading cause of cholangitis. However, in recent years, especially at tertiary referral centers, nonoperative biliary manipulations, often in patients with unresectable malignancies, have become the most common cause of cholangitis. As a result, the complete triad of fever and chills, jaundice, and abdominal pain, as originally described by Charcot, is now seen less frequently. Most patients still have leukocytosis and abnormal liver function tests, but many patients with indwelling tubes may develop cholangitis without significant jaundice. E. coli, Klebsiella species, and the enterococci remain the most frequently isolated organisms, and anaerobes including Bacteroides fragilis are recovered in 15% to 30% of patients. However, Enterobacter and Pseudomonas species, as well as yeasts, are now being isolated more frequently from patients with indwelling tubes, who often have been treated previously with antibiotics. Computed cholangiography usually is necessary to determine the cause and site of biliary obstruction. In the majority of patients with cholangitis, cholangiography can be delayed until the patient has been afebrile for a minimum of 24 to 48 hours. Initial therapy includes bowel rest, intravenous fluids, and antibiotics. Many antibiotic regimens are now available to cover the gram-negative aerobes, the enterococcus, and the anaerobes that are likely to be causing the biliary infection. The combination of a penicillin and an aminoglycoside has been the gold standard. However, recent studies suggest that the newer broad-spectrum penicillins provide adequate therapy for these patients. Only a small percentage (5%-10%) of patients with toxic cholangitis require emergency biliary decompression. The choice of percutaneous or endoscopic drainage should be made on the basis of the presumed site and cause of obstruction as well as local expertise. The nature of the biliary obstruction may be the most important determinant of outcome. At present, patients with end-stage malignant obstruction account for most of the deaths, whereas approximately 95% of patients survive an episode of cholangitis.

The occurrence and sources of natural antibody in human bile and serum against the O antigens of two Escherichia coli serotypes

Paired serum and bile samples from normal subjects as well as patients with biliary disease were tested for natural antibody to two individual Escherichia coli O antigens by ELISA. Serum antibody was most commonly of IgM and IgG class. Antibody was less frequently detected in bile and was more commonly IgM than IgA, with IgG activity detected infrequently. Little relation was apparent between antibody in paired samples; activity could be present in both serum and bile or in either fluid alone. Titres in paired samples also did not correspond when 'normalized' with respect to the concentrations of relevant isotypes; bile was frequently enriched for natural antibody as a proportion of total immunoglobulin compared with serum. Secretory component-bound antibody was detectable in some biles that contained IgA and/or IgM activity and in the serum of 33% of subjects with biliary disorders but not in normal sera. A series of paired samples taken from three individuals was also examined for antibody against each subject's own intestinal commensal E. coli. Serum IgM and IgG activity was present in all samples, but antibody in bile was less frequent and was of IgM or IgA class. These results suggest that natural antibody in human bile occurs independently of antibody in serum and that it is substantially derived from local sources.

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. Endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.

Urgent endoscopic drainage for acute suppurative cholangitis

105 patients with acute calculous cholangitis who did not respond to conservative management underwent urgent endoscopic drainage of the biliary system at a mean of 1.5 days after admission. Treatment was successful in 102 (97%) patients. 3 of the patients in whom drainage was not successful underwent emergency surgery, with 1 death. 3 patients died of uncontrolled sepsis despite successful endoscopic drainage. 1 patient died of a stroke. The overall mortality was 4.7%. Among those in shock 2 out of 4 drained after 72 h died, compared with 3 out of 38 drained before 72 h. There were no deaths in the group without shock irrespective of the timing of drainage.

Relationship of biliary pressure to cholangiovenous reflux during endoscopic retrograde balloon catheter cholangiography

In 32 patients undergoing endoscopic retrograde cholangiography with a balloon catheter, culture of bile, biliary pressure at maximal visualization of the biliary tract with iodinated contrast medium, serum iodine concentrations, and blood cultures before and after the procedure were obtained. There was a significant increase in the serum iodine concentration in five of nine patients (55.6%) with pressure between 22 cm H2O and 30 cm H2O and in nine of 13 patients (69.2%) with pressure above 30 cm H2O, while it remained low in 10 patients with pressure below 22 cm H2O. Two patients showed positive blood culture after the procedure, which yielded the same organisms as found in the bile. The biliary pressures in these two patients were 30.4 cm H2O and 38.0 cm H2O. These data suggest that during retrograde balloon catheter cholangiography: (1) cholangiovenous reflux of contrast medium develops with biliary pressure higher than 22 cm H2O, (2) the indicence of the cholangiovenous reflux increases as the pressure is elevated, and (3) regurgitation of bacteria occurs with pressure greater than 30 cm H2O. These findings are noteworthy because the number of patients who need direct cholangiography is increasing.

Cholangiovenous reflux pathways as defined by corrosion casting and scanning electron microscopy

Using corrosion casting and scanning electron microscopy of the rat biliary tree, we investigated the site and size of the pathways that allow bacteria to reflux from bile to blood. Nonobstructed rat biliary trees were injected retrograde with methylmethacrylate resin at a constant rate of 0.04 ml/min to volumes of 40, 60, 80, 120, 160, and 200 microliters. The infusion pressure was monitored and a pressure-volume curve was constructed. After polymerization and corrosion in 30 percent potassium hydroxide, the casts were examined with scanning electron microscopy. In addition, to identify the size of the reflux pathways, ceramic particles of 150 A, 1.7 mu, or 10 mu were added to the resin, and the studies were repeated. Finally, intact livers with casted biliary trees were processed and studied by scanning electron microscopy without corrosion. Scanning electron microscopy demonstrated fine anatomic detail of the cholangiovenous reflux pathway. At 40 microliters (20 cm water pressure), normal biliary radicals were filled. Between 40 and 80 microliters (20 to 50 cm water pressure), the cast material refluxed from the bile ductules into the spaces of Mall and Disse and then into the hepatic sinusoids. Filling of sinusoids continued at volumes between 80 to 160 microliters, and filling of collecting veins was seen above 160 microliters. Particles of 1.7 mu and smaller readily refluxed, but there was no sinusoidal reflux of casting material that contained particles of 10 mu. Casting without corrosion showed that the liver parenchyma remained intact. There was no evidence of reflux across hepatocytes. This study shows that cholangiovenous reflux occurs directly from bile ductules through the spaces of Mall and Disse into the hepatic sinusoids. The pathways measure between 1.7 and 10 mu. Since this is the path of least resistance, it may be of greater importance in the reflux of bacteria and toxins than other high-resistance pathways, for example, biliary canaliculi, tight junctions, or hepatocytes.

Infections associated with transhepatic biliary drainage devices

To determine the infectious complications associated with transhepatic biliary drainage devices, an analysis of the records of 38 patients who underwent placement of a pigtail catheter (n = 11), a Ring catheter/feeding tube (n = 13), or a Carey-Coons endoprosthesis (n = 15) was carried out. Nineteen infectious events occurred in 38 patients with 39 biliary devices. Infections consisted of bacteremia, cholangitis with and without documented bacteribilia, and intrahepatic abscesses and were frequently associated with obstruction (66.7 percent of infectious episodes). The most frequent organisms isolated from blood were Escherichia coli and Pseudomonas aeruginosa, and the most frequent organisms isolated from bile were P. aeruginosa, Klebsiella pneumoniae and Streptococcus faecalis. Trends for more frequent occurrence of neoplasms involving the gallbladder or biliary tract, recent surgical procedures and catheter manipulations in infected as compared with noninfected patients, and a delayed time to infection were noted in patients with an endoprosthesis.

Operative cholangiography with an antiseptic contrast solution. An experimental study in dogs

A new antiseptic contrast material, composed of sodium diatrizoate-meglumine diatrizoate and PVP-iodine solutions, was prepared and tested for operative cholangiography. It was tested in vitro, and in vivo in dogs and displayed satisfactory contrast radiologic features, and strong and rapid bactericidal action without detectable side effects. It seems to be promising in reducing the risk of bacterial spread during cholangiography.

Sump syndrome following choledochoduodenostomy and its endoscopic treatment

The clinical features of eight patients with 'sump syndrome' following side-to-side choledochoduodenostomy are reported. The syndrome is defined and its aetiology discussed with special reference to debris in the common bile duct, bacterial overgrowth and the clinical picture of acute cholangitis, which does not appear to be necessary for the diagnosis to be made. Five patients were successfully treated by endoscopic sphincterotomy and a sixth by endoscopic removal of food debris from the sump. The other two patients had further surgery.