Bacterial Cholangitis

Common Bile Duct Dilatation With Stones Indicates Requirement for Early Drainage in Patients With or Without Cholangitis

Background

Some patients with common bile duct (CBD) stones develop cholangitis requiring drainage, while others do not. The aims of this study were to elucidate the clinical differences among patients with CBD stones who required and did not require emergent drainage, and to identify risk factors for the development of cholangitis requiring emergent drainage in patients with silent CBD stones.

Methods

Clinical characteristics of consecutive patients with CBD stones who underwent endoscopic removal of stones or biliary drainage were analyzed retrospectively.

Results

Of 101 patients analyzed, 32 had moderate or severe cholangitis as the indication for emergent drainage, and the remaining 69 did not. Patients who required emergent drainage were more likely to have gallstones (P = 0.029), dilated CBD (> 10 mm) (P = 0.004) and larger CBD stones (P = 0.019). By multivariate analysis, CBD dilation was the only significant differentiating clinical characteristic of the patients who required emergent drainage (OR = 3.75, 95% CI: 1.41-9.96, P = 0.008). Of the 35 patients with silent bile duct stones, eight required emergent endoscopic drainage during the waiting period. CBD dilation was also the only significant risk factor for the development of moderate or severe cholangitis among patients with silent bile duct stones (OR = 10.18, 95% CI: 1.09-94.73, P = 0.042).

Conclusions

Dilated CBD (> 10 mm) was the only risk factor identified for requirement of early drainage in patients with CBD stones. Those who have silent CBD stones with CBD dilatation should undergo early drainage.

Management for CBD stone-related mild to moderate acute cholangitis: urgent versus elective ERCP

BACKGROUND

There is no doubt that urgent biliary decompression needs to be done in case of severe acute cholangitis. However, it remains to be determined how early biliary decompression should be performed and elective intervention would be comparable to urgent intervention, in case of mild to moderate choledocholithiasis associated cholangitis.

METHODS

One hundred ninety-five patients were enrolled who were diagnosed with mild to moderate cholangitis with common bile duct (CBD) stones between January 2006 and August 2010. They were divided into two groups according to door to intervention time, and urgent (≤24 h, n = 130) versus elective (>24 h, n = 82). Primary outcomes of this study were technical success rate (CBD stones removal) and clinical success rate (improvement of cholangitis) between the two groups. Hospital stay and intervention-related complications were also evaluated.

RESULTS

There was no statistically significant difference in technical, clinical success rate and intervention-related complications between the urgent and elective groups (P = 0.737, 0.285, 0.398, respectively). Patients in the urgent group had significantly shorter hospitalization than in the elective group (6.8 vs. 9.2 days, P < 0.001), and furthermore, intervention to discharge time was also significantly shorter by 1.1 days in the urgent group (P = 0.035). In terms of laboratory parameters, initial CRP level was the only factor correlated with hospital stay and intervention to discharge time.

CONCLUSIONS

This study demonstrates that urgent ERCP would be recommended in the management of patients with CBD stone-related mild to moderate acute cholangitis because of the advantage of short hospital stay and intervention to discharge time.

Comparison of the clinical characteristics and imaging findings of acute cholangitis with and without biliary dilatation

OBJECTIVE

To evaluate the causes of acute cholangitis without biliary dilatation and to compare the clinical characteristics and the imaging findings between patients with acute cholangitis with and without biliary dilatation.

METHODS

93 patients diagnosed with acute cholangitis underwent contrast-enhanced CT. Among them, 17 patients were classified as not having biliary dilatation (Group 1) and 76 patients were classified as having biliary dilatation (Group 2). The causes of acute cholangitis were evaluated in both groups. Clinical characteristics and imaging findings were compared between the two groups.

RESULTS

The causes of acute cholangitis without biliary dilatation included common bile duct (CBD) stones (n=11), CBD sludge (n=3), a passed stone (n=1) and unknown causes (n=2). The total bilirubin levels of Group 1 were significantly lower than those of Group 2 (p=0.001). By contrast, Group 1 had higher median alanine aminotransferase (ALT) levels than Group 2 (p=0.04). The length of hospital stay was significantly longer in Group 2 than in Group 1 patients (p<0.001). In the imaging findings, the extent of transient hepatic attenuation differences (THADs) (p=0.003) were significantly smaller in Group 1 than in Group 2.

CONCLUSION

CBD stones and sludge were the most common causes of acute cholangitis in patients without biliary dilatation. These patients showed lower levels of bilirubin and higher levels of ALT than those with acute cholangitis with biliary dilatation, and had a shorter duration of hospital stay. The extent of THADs was the only discriminative CT finding between the two groups.

ADVANCES IN KNOWLEDGE

Acute cholangitis can present without biliary dilatation on imaging, and the most common causes are CBD stones and sludge. The patients with acute cholangitis without biliary dilatation have different clinical characteristics and imaging findings compared with those with acute cholangitis presenting with biliary dilatation.

Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system

BACKGROUND/PURPOSE

We aimed to evaluate compliance with the clinical practice guidelines for acute cholangitis (Tokyo Guidelines) using the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system.

METHODS

We collected database data from 60,842 acute cholangitis patients, examining 10 recommendations in the Tokyo Guidelines. We counted how many recommendations had been complied with for every patient. The patient compliance score was defined as the rate of compliance with these recommendations (score 0 = 0% to score 10 = 100%). An aggregated patient compliance score was measured according to the severity of acute cholangitis. Severity was categorized as grade I (mild cholangitis; n = 49,630), grade II (moderate cholangitis; n = 10,444), and grade III (severe cholangitis; n = 768).

RESULTS

The mean patient compliance score was significantly higher for patients with grade III than for those with grades II and I (7.6 ± 2.1 vs. 6.5 ± 3.0 vs. 2.9 ± 0.9, p < 0.001, respectively). Multiple linear regression analysis revealed that the severity of acute cholangitis was the parameter most significantly associated with the patient compliance score. The standardized coefficient of grade III was higher than that of grade II (0.657 vs. 0.248, p < 0.001).

CONCLUSIONS

Compliance with the Tokyo Guidelines became higher in accordance with the severity of acute cholangitis.

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

BACKGROUND

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system.

METHODS

A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases).

RESULTS

Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725).

CONCLUSIONS

There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.

Cholangitis: Analysis of Admission Prognostic Indicators and Outcomes

Acute cholangitis is a life-threatening complication of biliary obstruction that is exacerbated by delays in diagnosis and treatment. Since the introduction of endoscopic retrograde cholangiography and endoscopic therapeutic modalities, few investigations have addressed admission prognostic indicators of adverse outcomes. A retrospective review of all patients with a diagnosis of acute cholangitis from 1995 to 2005 was performed. Primary endpoints were organ failure and death. One-hundred and seventeen patients met criteria for acute cholangitis. Only 49 (42%) had Charcot's triad and 3 (3%) had Reynolds’ pentad. One-hundred and four (89%) patients underwent biliary decompression, of which 79 (76%) were treated by endoscopic methods. There were 29 (25%) cases of organ failure and 9 (8%) deaths. The admission white blood cell (WBC) count ( P = 0.0003) and total bilirubin (TBili) ( P = 0.04) were statistically significant predictors of organ failure or death. With an admission of WBC ≥ 20,000 cells/mm3, the sensitivity, specificity, positive predictive value, and negative predictive value for organ failure and death were 50 per cent, 92 per cent, 63 per cent, and 88 per cent, respectively. A TBili of ≥10 mg/dL had sensitivity, specificity, positive predictive value, and negative predictive value of 56 per cent, 85 per cent, 21 per cent, and 96 per cent, respectively for predicting death. Admission WBC ≥ 20,000 cells/mm3 and TBili ≥ 10 mg/dL are selective predictors of adverse outcomes in acute cholangitis.

Biliary epithelial cell antibodies induce expression of toll-like receptors 2 and 3: a mechanism for post-liver transplantation cholangitis?

Studies to determine the role of preformed antibodies to biliary epithelial cells (BECs) in liver transplant rejections have been initiated. However, the clinical importance of these antibodies in the posttransplantation period still remains to be elucidated. Reactivity to BECs isolated from a normal healthy liver was investigated in sera of 56 patients before and after liver transplantation (LTX) using flow cytometry. Functional capacity of BEC antibodies was determined by the ability to induce expression of Toll-like receptors (TLRs) on BECs. Cytokine and chemokine production induced by BEC antibodies was determined by enzyme-linked immunosorbent assay. In all, 7 patients (13%) had BEC antibodies only pre-LTX, 14 (25%) only after LTX, 18 (32%) both before and after LTX, and 17 (30%) had no detectable antibodies. Presence of preformed BEC antibodies correlated with acute rejections (P < 0.03). Deposition of immunoglobulins in bile ducts was detected in biopsies of patients during rejections. Significantly higher numbers of patients with post-LTX antibodies (9 of 32) developed cholangitis, compared with 0 of 17 without antibodies (P < 0.02). Specificity studies indicated that these antibodies were both non-HLA- and HLA-specific. Normal BECs expressed mRNA but not the proteins for the TLRs. However, treatment with F(ab')2 fragments of BEC antibodies induced protein expression of TLRs 2 and 3 and significantly high production of interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1alpha, epithelial neutrophil activating peptide (ENA)-78, and IL-8. In conclusion, BEC antibodies via induction of TLR2 and TLR3 expression, as well as inflammatory cytokine and chemokine production may induce epithelial cell inflammatory responses to bacterial components and contribute to posttransplantation cholangitis.

MR imaging in abdominal emergencies

The use of MR imaging in the emergency setting is evolving. Clear indications include situations in need of contrast media when iodinated contrast cannot be administered or to facilitate assessments in pregnant patients and children when exposure to ionizing radiation is considered unacceptable. The availability of rapid, motion-immune sequences now makes MR imaging a feasible study in less cooperative patients extending the range of patients for whom a diagnostic study can be achieved. Capitalizing on the unique benefits of MR imaging there is optimism that MR imaging can eliminate test redundancy and impact patient care in a cost-effective manner. Further investigations are needed to identify the diagnostic algorithms for which this favorable use holds true.

Postoperative Bile Duct Strictures

The management of patients with postoperative biliary stricture is a challenging problem that spans across several disciplines. A team approach involving endoscopists, interventional radiologists, and biliary surgeons is crucial for the successful management of individuals with this complex problem. Hepaticojejunostomy is the therapy of choice. Prolonged stenting, either through the percutaneous route or through the endoscopic retrograde route, is an alternative. Stricture recurrence is not infrequent and requires lifelong follow-up.