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Jagtap N, Chavan D, Rughwani H, Memon SF, Lakhtakia S, Asif S, Kalapala R, Ramchandani M, Reddy DN. Impact of timing of ERCP on long term outcomes of ERCP for acute cholangitis - A single center retrospective study. Dig Liver Dis 2024:S1590-8658(24)00959-9. [PMID: 39245601 DOI: 10.1016/j.dld.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/29/2024] [Accepted: 08/11/2024] [Indexed: 09/10/2024]
Abstract
INTRODUCTION Acute cholangitis is a critical medical emergency. The association between the timing of ERCP and clinical outcomes of acute cholangitis is still debated. The current study aims to evaluate whether ERCP within 48 h (urgent) is associated with improved long term clinical outcomes. METHODS This study is a single-center retrospective analysis of a prospectively maintained database. All patients admitted with acute cholangitis as per Tokyo guidelines at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included. We evaluated the association between urgent ERCP and length of hospital stay, need for reintervention and readmissions, and mortality. RESULTS A total of consecutive 301 patients underwent ERCP for acute cholangitis; of which 217 patients (31.3 % females; mean age 54.02 ± 14.9 years) underwent urgent ERCP. The remaining 84 (32.1 % females; mean age 56.56 ± 13.9 years) underwent routine ERCP. Fifty-eight (26.7 %) and 22 (26.2 %) patients with Grade III underwent urgent and routine ERCP respectively. The median (IQR) hospital stay for urgent ERCP was 8.00 (6.00 - 11.00) days and for routine ERCP was 11.00(8.00 - 15.00; p value 0.0001), with similar hospital stay post ERCP (p 0.26). There was no significant difference in mortality upto one year between patients who underwent urgent (22.1 %;48/217) or routine ERCP (31.0 %;26/84, p 0.135). The cox proportional hazard model showed that mortality is independently associated with older age (HR 1.034;95 %CI: 1.013 - 1.054; p 0.001) and malignancy (HR 8.64;95 %CI:4.728 - 15.790; p 0.0001). There was no significant difference between two groups in terms of need for reinterventions and readmissions. CONCLUSIONS Urgent ERCP for acute cholangitis is associated comparable overall mortality, need for reinterventions, and readmissions with decreased total length of hospital stay. There is an unmet need to confirm these findings by randomized controlled studies.
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Affiliation(s)
- Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Digvijay Chavan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Hardik Rughwani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sana Fathima Memon
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shujaath Asif
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
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Xiong R, Xiong D, Wu Z, Xiao X. Meta-analysis of the effectiveness of early endoscopic treatment of Acute biliary pancreatitis based on lightweight deep learning model. BMC Gastroenterol 2024; 24:292. [PMID: 39198766 PMCID: PMC11351377 DOI: 10.1186/s12876-024-03361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 08/08/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Acute biliary pancreatitis (ABP) is a clinical common acute abdomen. After the first pancreatitis, relapse rate is high, which seriously affects human life and health and causes great economic burdens to family and society. According to a great many research findings, endoscopic retrograde cholangiopancreatography (ERCP) is an effective treatment method. However, whether ERCP should be performed in early stage of ABP is still controversial in clinical practice. METHODS Related articles were retrieved from Pubmed, Web of Science core library, Nature, Science Direct, and other databases published from January 2000 until now. The keywords included early ERCP, delayed ERCP, ABP, laparoscopy, and cholecystectomy, all which were connected by "or" and "and". The language of articles was not restricted during the retrieval and Review Manager5.3 was employed to perform meta-analysis of experimental data. Finally, a total of 8 eligible articles were selected, including 8,801 patients. RESULTS The results of the meta-analysis demonstrated that no remarkable differences were detected in the incidence of complications, mortality, and operation time between patients undergoing ERCP in early stage and those receiving delayed ERCP. However, the hospitalization time of patients in experimental group was notably shorter than that among patients in control group. CONCLUSINS Early ERCP treatment is as safe as late ERCP treatment for biliary pancreatitis, and can significantly shorten the hospital stay. Hence, the therapy was worthy of clinical promotion. The research findings provided reference and basis for clinical treatment of relevant diseases.
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Affiliation(s)
- Rihui Xiong
- Department of Hepatopancreatobiliary Surgery, Jiujiang City Key Laboratory of Cell Therapy, Jiujiang NO.1 People's Hospital, Jiujiang, 332000, Jiangxi, China
| | - Danjuan Xiong
- Department of Hepatopancreatobiliary Surgery, Jiujiang City Key Laboratory of Cell Therapy, Jiujiang NO.1 People's Hospital, Jiujiang, 332000, Jiangxi, China
| | - Zhaoping Wu
- Department of Hepatopancreatobiliary Surgery, Jiujiang City Key Laboratory of Cell Therapy, Jiujiang NO.1 People's Hospital, Jiujiang, 332000, Jiangxi, China
| | - Xifeng Xiao
- Department of Gastroenterology, Jiujiang City Key Laboratory of Cell Therapy, Jiujiang NO.1 People's Hospital, Jiujiang, 332000, Jiangxi, China.
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Le KHN, Qian AS, Nguyen M, Qiao E, Nguyen P, Singh S, Krinsky ML. The hospital frailty risk score as a predictor of readmission after ERCP. Surg Endosc 2024; 38:260-269. [PMID: 37989888 DOI: 10.1007/s00464-023-10531-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND AND AIMS The 30-day readmission rate is a nationally recognized quality measure with nearly one-fifth of patients being readmitted. This study aims to evaluate frailty, as measured by the hospital frailty risk score (HFRS), as a prognostic indicator for 30-day readmission after inpatient ERCP. METHODS We analyzed weighted discharge records from the 2017 Nationwide Readmissions Database (NRD) to identify patients undergoing ERCP between 01/01/2017 and 11/30/2017. Our primary outcome was the 30-day unplanned readmission rate in frail (defined as HFRS > 5) against non-frail (HFRS < 5) patients. A mixed effects multivariable logistic regression method was employed. RESULTS Among 68,206 weighted hospitalized patients undergoing ERCP, 31.3% were frail. Frailty was associated with higher 30-day readmission (OR 1.23, 95% CI [1.16-1.30]). Multivariable analysis showed a greater risk of readmission with cirrhosis (OR 1.26, 95% CI [1.10-1.45]), liver transplantation (OR 1.36, 95% CI [1.08-1.71]), cancer (OR 1.58, 95% CI [1.48-1.69]), and male gender (OR 1.24, 95% CI [1.18-1.31]). Frail patients also had higher mortality rate (1.8% vs 0.6%, p < 0.01)], longer LOS during readmission (6.7 vs 5.6 days, p < 0.01), and incurred more charges from both hospitalizations ($175,620 vs $132,519, p < 0.01). Sepsis was the most common primary indication for both frail and non-frail readmissions but accounted for a greater percentage of frail readmissions (17.9% vs 12.4%, p < 0.01). CONCLUSIONS Frailty is associated with higher readmission rates, mortality, LOS, and hospital charges for admitted patients undergoing ERCP. Sepsis is the leading cause for readmission. Independent risk factors for readmission include liver transplantation, cancer, cirrhosis, and male gender.
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Affiliation(s)
- Khanh Hoang Nicholas Le
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA
| | - Alexander S Qian
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA
| | - Mimi Nguyen
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA
| | - Edmund Qiao
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA
| | - Phuong Nguyen
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA
| | - Mary Lee Krinsky
- Division of Gastroenterology, Department of Medicine, University of California San Diego Medical Center, La Jolla, CA, 92103, USA.
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Tsou YK, Su YT, Lin CH, Liu NJ. Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes? World J Clin Cases 2023; 11:6984-6994. [PMID: 37946763 PMCID: PMC10631399 DOI: 10.12998/wjcc.v11.i29.6984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Whether clinical outcomes of acute cholangitis (AC) vary by etiology is unclear. AIM To compare outcomes in AC caused by malignant biliary obstruction (MBO) and common bile duct stones (CBDS). METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to AC caused by MBO (MBO group, n = 56) and CBDS (CBDS group, n = 460). Clinical and laboratory parameters were compared between the groups. Propensity score matching (PSM) created 55 matched pairs. Confounders used in the PSM analysis were age, sex, time to ERCP, and technical success of ERCP. The primary outcome comparison was 30-d mortality. The secondary outcome comparisons were intensive care unit (ICU) admission rate, length of hospital stay (LOHS), and 30-d readmission rate. RESULTS Compared with the CBDS group, the MBO group had significantly lower body temperature, percentage of abnormal white blood cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, and creatinine. Body temperature, percent abnormal white blood cell count, and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis. Platelet count, prothrombin time/international normalized ratio, and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group. The MBO group had a significantly higher percentage of severe AC (33.9% vs 22.0%, P = 0.045) and received ERCP later (median, 92.5 h vs 47.4 h, P < 0.001). However, the two differences were not found in the PSM analysis. The 30-d mortality (5.4% vs 0.7%, P = 0.019), ICU admission rates (12.5% vs 4.8%, P = 0.028), 30-d readmission rates (23.2% vs 8.0%, P < 0.001), and LOHS (median, 16.5 d vs 7.0 d, P < 0.001) were significantly higher or longer in the MBO group. However, only LOHS remained significant in the PSM analysis. Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality. CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients. Therefore, clinicians should remain vigilant in MBO patients with clinically suspected AC, and perform ERCP for biliary drainage as soon as possible.
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Affiliation(s)
- Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yi-Tse Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Wang M, Wadhwani SI, Cullaro G, Lai JC, Rubin JB. Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States. J Clin Gastroenterol 2023; 57:731-736. [PMID: 35997698 PMCID: PMC9938839 DOI: 10.1097/mcg.0000000000001743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/21/2022] [Indexed: 12/10/2022]
Abstract
GOALS We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis. BACKGROUND Few studies have evaluated the association between race and outcomes in patients with acute cholangitis. STUDY We analyzed United States hospitalizations from 2009 to 2018 using the Nationwide Inpatient Sample (NIS). We included patients 18 years old or above admitted with an ICD9/10 diagnosis of cholangitis. Race/ethnicity was categorized as White, Black, Hispanic, or Other. We used multivariable regression to determine the association between race/ethnicity and in-hospital outcomes of interest, including endoscopic retrograde cholangiopancreatography (ERCP), early ERCP (<48 h from admission), length of stay (LOS), and in-hospital mortality. RESULTS Of 116,889 hospitalizations for acute cholangitis, 70% identified as White, 10% identified as Black, 11% identified as Hispanic, and 9% identified as Other. The proportion of non-White patients increased over time. On multivariate analysis controlling for clinical and sociodemographic variables, compared with White patients, Black patients had higher in-hospital mortality (adjusted odds ratio: 1.4, 95% confidence interval: 1.2-1.6, P <0.001). Black patients were also less likely to undergo ERCP, more likely to undergo delayed ERCP, and had longer LOS ( P <0.001 for all). CONCLUSIONS In this contemporary cohort of hospitalized patients with cholangitis, Black race was independently associated with fewer and delayed ERCP procedures, longer LOS, and higher mortality rates. Future studies with more granular social determinants of health data should further explore the underlying reasons for these disparities to develop interventions aimed at reducing racial disparities in outcomes among patients with acute cholangitis.
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Affiliation(s)
| | | | - Giuseppe Cullaro
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jessica B Rubin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
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Li K, Hu X, Lu Q, Zhang H, Zhou J, Tian S, Zhou F. Analysis of Pathogenic Bacteria Distribution and Related Factors in Recurrent Acute Cholangitis. Infect Drug Resist 2023; 16:4729-4740. [PMID: 37492797 PMCID: PMC10364819 DOI: 10.2147/idr.s418752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Background To evaluate the risk factors and prognosis of patients with acute cholangitis recurrence. Methods A total of 503 patients with acute cholangitis admitted to the First Affiliated Hospital of Chongqing Medical University between July 2013 and January 2022 were included in this retrospective observational study, who were followed up for 360 days and divided into relapse group and non-recurrence group according to the recurrence of acute cholangitis. Risk factors and prognosis of patients with acute cholangitis recurrence were analyzed by univariate, multivariate analyses and proportional hazards model. Results A total of 161 patients with recurrent acute cholangitis were identified. Recurrent acute cholangitis usually occurred within 125 days; Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis, and Enterococcus faecium was the most common positive record both in blood and bile culture. In the multivariate analysis, abdominal pain (OR = 2.448, 95% CI = 1.196-5.010, P = 0.014), bile stones (OR = 2.429, 95% CI = 1.024-5.762, P = 0.044), diabetes (OR = 1.790, 95% CI = 1.007-3.182, P = 0.047), pathogen (OR = 3.305, 95% CI = 1.932-5.654, P<0.001), and chronic kidney disease (OR = 2.500, 95% CI = 1.197-5.221, P = 0.015) may be ascertained as the risk factors of acute cholangitis recurrence. The recurrence of acute cholangitis was identified as an independent risk factor for patient death (HR = 4.524, 95% CI = 1.426-14.357, P = 0.010) by Cox proportional-hazards regression. Conclusion Abdominal pain, bile stones, diabetes and chronic kidney disease may be risk factors of acute cholangitis recurrence. Patients with recurrent acute cholangitis have poor prognosis and high mortality. Early control of recurrent risk factors and active intervention are beneficial to high-risk patients.
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Affiliation(s)
- Kaili Li
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xiaoxue Hu
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Quanyi Lu
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Heng Zhang
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jiayi Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shijing Tian
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Fachun Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Fridgeirsson HF, Konradsson M, Vesteinsdottir E, Bjornsson ES. Incidence and outcomes in patients with acute cholangitis: a population-based study. Scand J Gastroenterol 2023; 58:1484-1490. [PMID: 37409689 DOI: 10.1080/00365521.2023.2231585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The importance of early ERCP (endoscopic retrograde cholangiopancreatography) in patients with acute cholangitis (AC) is controversial. The aims were to compare outcomes in those who had early ERCP within 24 h from diagnosis and those who had ERCP undertaken later and examine the general prognosis of AC patients. METHODS A prospective endoscopic database was used to identify all patients who underwent ERCP 2010-2021 at Landspitali University Hospital, diagnosed with cholangitis (k83.0) or calculus of bile duct with cholangitis (k80.3) according to ICD-10 diagnostic codes. Tokyo guidelines were used to verify the diagnosis and severity. Sepsis was analyzed by the Sepsis-3 criteria. RESULTS A total of 240 patients met the inclusion criteria, 107 women (45%), median age 74 years, mostly due to gallstones (75%) and malignancy (19%), 61 (25%) underwent ERCP early. Overall 30-day mortality was 3.3% and was not significantly different between the early and late ERCP groups (4.9% vs 2.5% respectively). Patients who underwent early ERCP were more likely to have severe cholangitis according to the Tokyo guidelines criteria than those who underwent ERCP later (31% vs 18%, p = 0.047) but had a shorter median hospital stay (4 vs. 6 days, p = 0.006). Sepsis was more common among those who had ERCP early than those who had late ERCP (33% vs 19%, p = 0.033). CONCLUSIONS The results indicate that for patients with AC the timing of ERCP is an important factor influencing the hospital stay, with shorter hospital stay for patients receiveing ERCP within 24 h, despite more severe cholangitis at diagnosis.
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Affiliation(s)
| | - M Konradsson
- Divison of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
| | - E Vesteinsdottir
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland
| | - E S Bjornsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Divison of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
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Impact of the Timing of Endoscopic Retrograde Cholangiopancreatography for the Treatment of Acute Cholangitis: A Meta-analysis and Systematic Review. Surg Laparosc Endosc Percutan Tech 2022; 32:764-769. [PMID: 36223305 PMCID: PMC9719833 DOI: 10.1097/sle.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/06/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis (AC) has not been unequivocally established. AIMS To perform a meta-analysis of the outcomes associated with particular timings of ERCP for AC. METHODS A systematic literature search was conducted for studies of ERCP for AC, and then a meta-analysis of the in-hospital mortality (IHM), 30-day mortality, and length of hospital stay (LHS) was performed. RESULTS Seven non-randomized studies of 88,562 patients were considered appropriate for inclusion. Compared with performing ERCP more than 24 hours after admission, ERCP within 24 hours was associated with lower IHM ( P <0.0004), but no difference in 30-day mortality ( P =0.38) was found between the 2 groups. ERCP performed <48 hours after admission was associated with a lower IHM and 30-day mortality ( P <0.00001 and P =0.03) than ERCP performed >48 hours after admission. In addition, ERCP performed within 24 or 48 hours was associated with a shorter LHS ( P <0.00001 and P <0.00001, respectively). CONCLUSION ERCP within 48 hours of admission is superior to subsequent ERCP with respect to IHM, 30-day mortality, and LHS, and ERCP performed within 24 hours is associated with lower IHM and LHS.
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Lu ZQ, Zhang HY, Su CF, Xing YY, Wang GX, Li CS. Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study. World J Gastroenterol 2022; 28:3934-3945. [PMID: 36157549 PMCID: PMC9367232 DOI: 10.3748/wjg.v28.i29.3934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/25/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.
AIM To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.
METHODS In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].
RESULTS Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).
CONCLUSION Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.
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Affiliation(s)
- Zhao-Qing Lu
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Han-Yu Zhang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chen-Fen Su
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yue-Yan Xing
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Guo-Xing Wang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chun-Sheng Li
- Emergency and Critical Care Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Chan KS, Shelat VG. Klebsiella pneumoniae Bacteremia is Associated with Higher Mortality in Acute Calculous Cholangitis as Compared to Escherichia coli Bacteremia. World J Surg 2022; 46:1678-1685. [PMID: 35419623 DOI: 10.1007/s00268-022-06559-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute cholangitis (AC) is a potentially life-threatening infection involving the biliary system. The two commonest bacteria involved are Escherichia coli (EC) followed by Klebsiella pneumoniae (KP). Microbiology is a prognostic factor for several pathologies but not for AC. We aim to investigate clinical outcomes between KP bacteremia vs. EC bacteremia in AC. METHODS This is a retrospective cohort study of patients diagnosed with calculous AC (January-December 2016). Study outcomes include the length of hospitalization stay, in-hospital mortality, 30-day, and 90-day mortality. Univariate and multivariate logistic regression was used to establish correlations. RESULTS We included 141 patients (KP (n = 29), EC (n = 112)) with overall median age of 82.2 and similar gender distribution. Most patients had Grade II AC (n = 59, 41.8%). Patient demographics were comparable. KP bacteremia had lower median platelet count (KP:168 × 109/L vs. EC:200 × 109/L; p = 0.025). Overall 30-day and 90-day mortality were 9.2 and 10.6%, respectively. Multivariate analysis showed KP bacteremia had higher 30-day (Odds ratio (OR) 6.09, (95% Confidence Interval (CI):1.27-29.10), p = 0.024) and 90-day mortality (OR 6.10, 95% CI: 1.39-26.76, p = 0.017). The length of hospitalization stay was comparable. Subgroup analysis of endoscopic retrograde cholangiopancreatogram patients showed comparable outcomes. CONCLUSION KP bacteremia is associated with lower platelet count and higher 30-day and 90-day mortality than EC. More studies are required to establish if inferior outcomes of KP bacteremia are associated with antimicrobial resistance.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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11
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Akshintala VS, Singh A, Singh VK. Prevention and Management of Complications of Biliary Endoscopy. Gastrointest Endosc Clin N Am 2022; 32:397-409. [PMID: 35691688 DOI: 10.1016/j.giec.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA.
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12
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Khamaysi I, Taha R. ERCP for severe acute cholangitis: The earlier, the better. TURKISH JOURNAL OF GASTROENTEROLOGY 2021; 31:78-79. [PMID: 32009619 DOI: 10.5152/tjg.2020.19103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Iyad Khamaysi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology Rambam Health care Campus, Haifa, Israel
| | - Rana Taha
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology Rambam Health care Campus, Haifa, Israel
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13
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Buxbaum JL, Buitrago C, Lee A, Elmunzer BJ, Riaz A, Ceppa EP, Al-Haddad M, Amateau SK, Calderwood AH, Fishman DS, Fujii-Lau LL, Jamil LH, Jue TL, Kwon RS, Law JK, Lee JK, Naveed M, Pawa S, Sawhney MS, Schilperoort H, Storm AC, Thosani NC, Qumseya BJ, Wani S. ASGE guideline on the management of cholangitis. Gastrointest Endosc 2021; 94:207-221.e14. [PMID: 34023065 DOI: 10.1016/j.gie.2020.12.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.
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Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Carlos Buitrago
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Alice Lee
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Badih Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ahsun Riaz
- Department of Vascular and Interventional Radiology, Northwestern Medicine, Chicago, Illinois, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammed Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Audrey H Calderwood
- Department of Gastroenterology and Hepatology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health, Royal Oak, Michigan, USA, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Richard S Kwon
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Advent Health Medical Group, Department of Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hannah Schilperoort
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis. Clin Transl Gastroenterol 2021; 11:e00158. [PMID: 32352721 PMCID: PMC7145040 DOI: 10.14309/ctg.0000000000000158] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Although early biliary drainage improves outcomes in patients with acute cholangitis, the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) is controversial. Our aim was to evaluate the impact of timing of ERCP on mortality in hospitalized patients with acute cholangitis.
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15
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Chan KS, Mohan R, Low JK, Junnarkar SP, Huey CWT, Shelat VG. Elderly patients (≥ 80 years) with acute calculous cholangitis have similar outcomes as non-elderly patients (< 80 years): Propensity score-matched analysis. World J Hepatol 2021; 13:456-471. [PMID: 33959227 PMCID: PMC8080552 DOI: 10.4254/wjh.v13.i4.456] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/06/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cholangitis (AC) is a disease spectrum with varying extent of severity. Age ≥ 75 years forms part of the criteria for moderate (Grade II) severity in both the Tokyo Guidelines (TG13 and TG18). Aging is associated with reduced physiological reserves, frailty, and sarcopenia. However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases. There is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with AC.
AIM To investigate the effect of age (≥ 80 years) on AC's morbidity and mortality using propensity score matching (PSM).
METHODS This is a single-center retrospective cohort study of all patients diagnosed with calculous AC (January 2016 to December 2016) and ≥ 80 years old (January 2012 to December 2016) at a tertiary university-affiliated teaching hospital. Inclusion criteria were patients who were treated for suspected or confirmed AC secondary to biliary stones. Patients with AC on a background of hepatobiliary malignancy, indwelling permanent metallic biliary stents, or concomitant pancreatitis were excluded. Elderly patients were defined as ≥ 80 years old in our study. A 1:1 PSM analysis was performed to reduce selection bias and address confounding factors. Study variables include comorbidities, vital parameters, laboratory and radiological investigations, and type of biliary decompression, including the time for endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes include in-hospital mortality, 30-d and 90-d mortality. Length of hospital stay (LOS) was the secondary outcome.
RESULTS Four hundred fifty-seven patients with AC were included in this study (318 elderly, 139 non-elderly). PSM analysis resulted in a total of 224 patients (112 elderly, 112 non-elderly). The adoption of ERCP between elderly and non-elderly was similar in both the unmatched (elderly 64.8%, non-elderly 61.9%, P = 0.551) and matched cohorts (elderly 68.8% and non-elderly 58%, P = 0.096). The overall in-hospital mortality, 30-d mortality and 90-d mortality was 4.6%, 7.4% and 8.5% respectively, with no statistically significant differences between the elderly and non-elderly in both the unmatched and matched cohorts. LOS was longer in the unmatched cohort [elderly 8 d, interquartile range (IQR) 6-13, vs non-elderly 8 d, IQR 5-11, P = 0.040], but was comparable in the matched cohort (elderly 7.5 d, IQR 5-11, vs non-elderly 8 d, IQR 5-11, P = 0.982). Subgroup analysis of patients who underwent ERCP demonstrated the majority of the patients (n = 159/292, 54.5%) had delayed ERCP (> 72 h from presentation). There was no significant difference in LOS, 30-d mortality, 90-d mortality, and in-hospital mortality in patients who had delayed ERCP in both the unmatched and matched cohort (matched cohort: in-hospital mortality [n = 1/42 (2.4%) vs 1/26 (3.8%), P = 0.728], 30-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], 90-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], and LOS (median 8.5 d, IQR 6-11.3, vs 8.5 d, IQR 6-15.3, P = 0.929).
CONCLUSION Mortality is indifferent in the elderly (≥ 80 years old) and non-elderly patients (< 80 years old) with AC.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- MOH Holdings, Singapore 099253, Singapore
| | - Ramkumar Mohan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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16
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Park N, Lee SH, You MS, Kim JS, Huh G, Chun JW, Cho IR, Paik WH, Ryu JK, Kim YT. Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction. BMC Gastroenterol 2021; 21:175. [PMID: 33865307 PMCID: PMC8052855 DOI: 10.1186/s12876-021-01755-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/07/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is a lack of studies regarding the optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in patients with cholangitis caused by distal malignant biliary obstruction (MBO). This study aims to investigate the optimal timing of ERCP in patients with acute cholangitis associated with distal MBO with a naïve papilla. METHODS A total of 421 patients with acute cholangitis, associated with distal MBO, were enrolled for this study. An urgent ERCP was defined as being an ERCP performed within 24 h following emergency room (ER) arrival, and early ERCP was defined as an ERCP performed between 24 and 48 h following ER arrival. We evaluated both 30-day and 180-day mortality as primary outcomes, according to the timing of the ERCP. RESULTS The urgent ERCP group showed the lowest 30-day mortality rate (2.2%), as compared to the early and delayed ERCP groups (4.3% and 13.5%) (P < 0.001). The 180-day mortality rate was lowest in the urgent ERCP group, followed by early ERCP and delayed ERCP groups (39.4%, 44.8%, 60.8%; P = 0.006). A subgroup analysis showed that in both the primary distal MBO group, as well as in the moderate-to-severe cholangitis group, the urgent ERCP had significantly improved in both 30-day and 180-day mortality rates. However, in the secondary MBO and mild cholangitis groups, the difference in mortality rate between urgent, early, and delayed ERCP groups was not significant. CONCLUSIONS In patients with acute cholangitis associated with distal MBO, urgent ERCP might be helpful in improving the prognosis, especially in patients with primary distal MBO or moderate-to-severe cholangitis.
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Affiliation(s)
- Namyoung Park
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sang Hyub Lee
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Min Su You
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Joo Seong Kim
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Gunn Huh
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jung Won Chun
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - In Rae Cho
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Woo Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Kon Ryu
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yong-Tae Kim
- Division of Gastroenterology, Department of Internal Medicine, Liver Research Institute, College of Medicine, Seoul National University Hospital, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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17
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Lavillegrand JR, Mercier-Des-Rochettes E, Baron E, Pène F, Contou D, Favory R, Préau S, Galbois A, Molliere C, Miailhe AF, Reignier J, Monchi M, Pichereau C, Thietart S, Vieille T, Piton G, Preda G, Abdallah I, Camus M, Maury E, Guidet B, Dumas G, Ait-Oufella H. Acute cholangitis in intensive care units: clinical, biological, microbiological spectrum and risk factors for mortality: a multicenter study. Crit Care 2021; 25:49. [PMID: 33549136 PMCID: PMC7866656 DOI: 10.1186/s13054-021-03480-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/25/2021] [Indexed: 12/24/2022] Open
Abstract
Background Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC). Methods Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis. Results Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5–11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50–147] and 19.1 µg/L [5.3–54.8]. Sixty-three percent of patients (n = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54–0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05–1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08–1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12–1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45–5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30–6.22], p = 0.02). Conclusions In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.
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Affiliation(s)
- Jean-Rémi Lavillegrand
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France.,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
| | | | - Elodie Baron
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Cochin, 75014, Paris Cedex 12, France
| | - Frédéric Pène
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Cochin, 75014, Paris Cedex 12, France
| | - Damien Contou
- Centre Hospitalier Argenteuil, Service de réanimation polyvalente et unité de surveillance continue, 95107, Argenteuil, France
| | - Raphael Favory
- Centre Hospitalier Universitaire Lille, Service de réanimation générale, Hôpital Salengro, 59037, Lille, France
| | - Sébastien Préau
- Centre Hospitalier Universitaire Lille, Service de réanimation générale, Hôpital Salengro, 59037, Lille, France
| | - Arnaud Galbois
- Service de réanimation polyvalente, Hôpital Privé Claude Galien, 91480, Quincy-sous-Sénart, France
| | - Chloé Molliere
- Service de réanimation polyvalente, Hôpital Privé Claude Galien, 91480, Quincy-sous-Sénart, France
| | - Arnaud-Félix Miailhe
- Service de médecine intensive et réanimation, Centre Hospitalier Universitaire Nantes, Hôtel-Dieu, 44000, Nantes, France
| | - Jean Reignier
- Service de médecine intensive et réanimation, Centre Hospitalier Universitaire Nantes, Hôtel-Dieu, 44000, Nantes, France
| | - Mehran Monchi
- Groupe Hospitalier Sud Île-De-France (GHSIF), Service de réanimation polyvalente, Hôpital de Melun-Sénart, 77000, Melun, France
| | - Claire Pichereau
- Centre Hospitalier Intercommunal Poissy Saint-Germain-en-Laye, Service de réanimation, Hôpital de Poissy, 78303, Poissy, France
| | - Sara Thietart
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Thibault Vieille
- Centre Hospitalier Régional Universitaire Besançon, Service de réanimation médicale, Hôpital Jean Minjoz, 25030, Besançon, France
| | - Gael Piton
- Centre Hospitalier Régional Universitaire Besançon, Service de réanimation médicale, Hôpital Jean Minjoz, 25030, Besançon, France
| | - Gabriel Preda
- Centre Hospitalier de Saint-Denis, Service de réanimation et soins continus, Hôpital Delafontaine, 93205, Saint-Denis, France
| | - Idriss Abdallah
- Centre Hospitalier Sud Seine-et-Marne, Service de réanimation, Hôpital Fontainebleau, 77300, Fontainebleau, France
| | - Marine Camus
- Sorbonne Université, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Centre d'endoscopie digestive, Hôpital Saint-Antoine, Paris, France
| | - Eric Maury
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France
| | - Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France
| | - Guillaume Dumas
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Paris, France
| | - Hafid Ait-Oufella
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine intensive et réanimation, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Sorbonne Université, Paris, France. .,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
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Krill TS, Crain R, Al-Saadi Y, Stubbs S, Roark R, Chatila A, Haddad C, Kaushik C, Marcondes F, Guturu P, Parupudi S. Predictors of 30-Day Readmission After Inpatient Endoscopic Retrograde Cholangiopancreatography: A Single-Center Experience. Dig Dis Sci 2020; 65:1481-1488. [PMID: 31587154 DOI: 10.1007/s10620-019-05870-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The 30-day hospital readmission rate is a nationally recognized quality measure. Nearly one-fifth of medicare beneficiaries are hospitalized within 30 days of discharge, resulting in a cost of over $26 billion dollars annually. Endoscopic retrograde cholangiopancreatography (ERCP) remains the endoscopic procedure with the highest risk of morbidity and mortality. We set out to analyze the clinical characteristics predictive of 30-day readmission after an inpatient ERCP. METHODS We performed a retrospective chart review of all inpatient ERCPs performed at our institution between 12/1/2014 and 9/30/2018. Clinical characteristics and outcomes of these patients were compared to determine predictors of 30-day readmission. RESULTS A total of 497 inpatient ERCP procedures done for biliary or pancreatic indications, constituting 483 patients, were identified. There were 52 readmissions that occurred among 48 patients within 30 days of discharge. Basic demographic characteristics were similar between both groups. Comorbidities were significantly higher in those who were readmitted. Multivariate analysis revealed significantly greater odds of readmission with prior liver transplantation (OR = 4.15), cirrhosis (OR = 3.20), and pancreatic duct stent placement (OR = 2.56). Subgroup analysis for biliary indications revealed cholecystectomy before discharge and early ERCP to be protective against readmission. CONCLUSION A history of liver transplantation and cirrhosis are predictive of increased 30-day readmission rates after an inpatient ERCP. Pancreatic duct stent placement is associated with readmission; however, this phenomenon is likely related to stenting for pancreatic endotherapy. Cholecystectomy before discharge and early ERCP are predictive of decreased need for readmission in procedures done for biliary indications.
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Affiliation(s)
- Timothy S Krill
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA.
| | - Rebecca Crain
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yamam Al-Saadi
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Samantha Stubbs
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Russell Roark
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ahmed Chatila
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Christina Haddad
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Chandni Kaushik
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Felippe Marcondes
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Praveen Guturu
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0570, USA
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19
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Iqbal U, Khara HS, Hu Y, Khan MA, Ovalle A, Siddique O, Sun H, Shellenberger MJ. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2020; 91:753-760.e4. [PMID: 31628955 DOI: 10.1016/j.gie.2019.09.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 09/27/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Acute cholangitis is characterized by abdominal pain, fever, and jaundice. Most patients respond to medical management with intravenous hydration and antibiotics. About 20% to 30% require biliary drainage, and ERCP is the procedure of choice. We conducted a systematic review and meta-analysis to evaluate the impact of emergent biliary drainage on patient outcomes. METHODS A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to April 2019 to identify all studies that evaluated the impact of timing of ERCP on patient outcomes. Our primary outcome was in-hospital mortality (IHM), and secondary outcomes were length of stay (LOS), organ failure, and 30-day mortality. Fixed and random effects models were used to generate pooled measures of IHM, 30-day mortality, and LOS. RESULTS Nine observational studies involving 7534 patients were included in the primary meta-analysis. IHM was significantly lower in patients who underwent emergent biliary drainage within 48 hours (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.28-0.98). As a sensitivity analysis, we pooled the data from 2 population registry studies of 81,893 patients, which yielded consistent results for the main outcomes. LOS was also significantly lower in patients who underwent ERCP within 48 hours with a mean difference of 5.56 days (95% CI, 1.59-9.53). Patients who underwent emergent ERCP also had lower odds of 30-day mortality (OR, 0.39; 95% CI, 0.14-1.08) and organ failure (OR, 0.69; 95% CI, 0.33-1.46). CONCLUSIONS Our study reveals that performing emergent ERCP within 48 hours in patients with acute cholangitis is associated with lower IHM, 30-day mortality, organ failure, and shorter LOS.
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Affiliation(s)
- Umair Iqbal
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - Harshit S Khara
- National Pancreas Foundation Center at Geisinger Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Nutrition, Geisinger Medical Center, Danville, Pennsylvania
| | - Yirui Hu
- Biomedical & Translational Informatics Institute, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - Muhammad Ali Khan
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anais Ovalle
- Department of Infectious Disease, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Osama Siddique
- Department of Gastroenterology and Hepatology, University of Connecticut, Farmington, Connecticut
| | - Haiyan Sun
- Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - Matthew Joshua Shellenberger
- Department of Gastroenterology and Hepatology, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania, USA
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20
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Parikh MP, Garg R, Chittajallu V, Gupta N, Sarvepalli S, Lopez R, Thota PN, Siddiki H, Bhatt A, Chahal P, Jang S, Stevens T, Vargo J, McCullough A, Sanaka MR. Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database. Surg Endosc 2020; 35:223-231. [PMID: 31950275 DOI: 10.1007/s00464-020-07384-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. METHODS We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. RESULTS From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69). CONCLUSIONS AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.
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Affiliation(s)
- Malav P Parikh
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Vibhu Chittajallu
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Niyati Gupta
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Shashank Sarvepalli
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Rocio Lopez
- Department of Biostatistics and Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Hassan Siddiki
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Arthur McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA. .,Department of Gastroenterolgy, Cleveland Clinic Foundation, Desk Q39500 Euclid Avenue, Cleveland, OH, 44195, USA.
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21
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Soares PFDC, Gestic MA, Utrini MP, Callejas-Neto F, Chaim EA, Cazzo E. Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study. SAO PAULO MED J 2019; 137:491-497. [PMID: 32159634 PMCID: PMC9754274 DOI: 10.1590/1516-3180.2019.0109170919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 09/17/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING Cross-sectional study at a tertiary-level university hospital. METHODS Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.
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Affiliation(s)
- Pedro França da Costa Soares
- MD. Resident Physician, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Martinho Antonio Gestic
- MD, MSc. Assistant Lecturer, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Murillo Pimentel Utrini
- MD. Attending Physician, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Francisco Callejas-Neto
- MD, MSc. Assistant Professor, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Elinton Adami Chaim
- MD, PhD. Full Professor, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Everton Cazzo
- MD, PhD. Adjunct Professor, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
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22
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Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, Cortessis VK, Schilperoort H, Kysh L, Matsuoka L, Yachimski P, Agrawal D, Gurudu SR, Jamil LH, Jue TL, Khashab MA, Law JK, Lee JK, Naveed M, Sawhney MS, Thosani N, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89:1075-1105.e15. [PMID: 30979521 PMCID: PMC8594622 DOI: 10.1016/j.gie.2018.10.001] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022]
Abstract
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, California, USA
| | - Shahnaz Sultan
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology & Nutrition, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Victoria K Cortessis
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hannah Schilperoort
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lynn Kysh
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lea Matsuoka
- Division of Hepatobiliary Surgery & Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Suryakanth R Gurudu
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
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23
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Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Unchanged mortality in patients with acute cholangitis despite an increase in malignant etiologies - a 25-year epidemiological study. Scand J Gastroenterol 2019; 54:335-341. [PMID: 30946608 DOI: 10.1080/00365521.2019.1585568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background and aims: Acute cholangitis (AC) is a rare but serious condition, with an incidence of 7.0 per 10,000 people and mortality rates up to 10%. The aim of this study was to describe changes in obstruction etiology, comorbidities, clinical factors, and mortality among AC patients during a 25-year period. Methods: Using a database of 11,563 consecutive ERCP-procedures performed from 1990-2015 at Odense University Hospital, we identified all AC cases during that period. Clinical and epidemiological data were collected from the database and the Danish Patient Registry. Association with 30-day mortality was investigated using multiple logistic regression analysis with adjustment for confounding factors. Results: In total, 775 consecutive and individual cases of AC were included. Among cases, 42% (n = 326) were of malignant etiology, with an increasing incidence over time (regression coefficient [95% CI]: 0.03 [0.01-0.04] per year; p = .01). Mean Charlson Comorbidity Index was 1.4, with an increase over time (regression coefficient [95% CI]: 0.04 [0.03-0.05] per year; p < .01). Malignant obstruction etiology was associated with 30-day mortality (OR [95% CI]: 1.11 [1.04-1.18]; p < .01). Overall 30-day mortality was 12% (n = 91). After adjustment for confounding factors, no significant changes in 30-day mortality were observed over time (OR [95% CI]: 1 [1-1.00]; p = .91 per year). Conclusion: Significant increases in the incidence of malignant obstruction etiology and severity of comorbidities among AC patients were observed during the study period. Despite those findings, 30-day mortality remained unchanged, potentially reflecting a general improvement in the management of AC.
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Affiliation(s)
- Ming Tan
- a Department of Medical Gastroenterology S , Odense University Hospital , Odense , Denmark
| | | | - Stig Borbjerg Laursen
- a Department of Medical Gastroenterology S , Odense University Hospital , Odense , Denmark
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24
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Mulki R, Shah R, Qayed E. Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis. World J Gastrointest Endosc 2019; 11:41-53. [PMID: 30705731 PMCID: PMC6354111 DOI: 10.4253/wjge.v11.i1.41] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/28/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the effect of early vs late endoscopic retrograde cholangiopancreatography (ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.
METHODS We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day (days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure, acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with in-hospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex, severe disease and comorbidities.
RESULTS Four thousand five hundred and seventy patients satisfied the inclusion criteria; with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs 2.4%, adjusted odds ratio (aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality (1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions (9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group (6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group ($21459 vs $16939, P < 0.0001).
CONCLUSION Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.
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Affiliation(s)
- Ramzi Mulki
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
| | - Rushikesh Shah
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
- Grady Memorial Hospital, Emory University, Atlanta, GA 30303, United States
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25
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Terauchi T, Shinozaki H, Shinozaki S, Sasakura Y, Kimata M, Furukawa J, Lefor AK, Ogata Y, Kobayashi K. Single-Stage Endoscopic Stone Extraction and Cholecystectomy during the Same Hospitalization. Clin Endosc 2018; 52:59-64. [PMID: 30300983 PMCID: PMC6370930 DOI: 10.5946/ce.2018.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/27/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS The clinical impact of single-stage endoscopic stone extraction by endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy during the same hospitalization remains elusive. This study aimed to determine the efficacy and safety of single-stage ERCP and cholecystectomy during the same hospitalization in patients with cholangitis. METHODS We retrospectively reviewed the medical records of 166 patients who underwent ERCP for mild to moderate cholangitis due to choledocholithiasis secondary to cholecystolithiasis from 2012 to 2016. RESULTS Complete stone extraction was accomplished in 92% of patients (152/166) at the first ERCP. Among 152 patients who underwent complete stone extraction, cholecystectomy was scheduled for 119 patients (78%). Cholecystectomy was performed during the same hospitalization in 89% of patients (106/119). We compared two groups of patients: those who underwent cholecystectomy during the same hospitalization (n=106) and those who underwent cholecystectomy during a subsequent hospitalization (n=13). In the delayed group, cholecystectomy was performed about three months after the first ERCP. There were no significant differences between the groups in terms of operative time, rate of postoperative complications, and interval from cholecystectomy to discharge. CONCLUSION Single-stage endoscopic stone extraction is recommended in patients with mild to moderate acute cholangitis due to choledocholithiasis. The combination of endoscopic stone extraction and cholecystectomy during the same hospitalization is safe and feasible.
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Affiliation(s)
- Toshiaki Terauchi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Satoshi Shinozaki
- Shinozaki Medical Clinic, Tochigi, Japan.,Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yuichi Sasakura
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Masaru Kimata
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Junji Furukawa
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Yoshiro Ogata
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Kenji Kobayashi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
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26
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No Association of Timing of Endoscopic Biliary Drainage with Clinical Outcomes in Patients with Non-severe Acute Cholangitis. Dig Dis Sci 2018; 63:1937-1945. [PMID: 29663264 DOI: 10.1007/s10620-018-5058-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/05/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for acute cholangitis. Despite the established effectiveness of urgent biliary drainage in patients with severe acute cholangitis, the indication of this procedure for non-severe acute cholangitis is controversial. AIMS To assess the safety of elective drainage (≥ 12 h of admission) for non-severe acute cholangitis. METHODS We retrospectively identified 461 patients with non-severe acute cholangitis who underwent endoscopic biliary drainage. Using linear regression models with adjustment for a variety of potential confounders, we compared elective versus urgent biliary drainage (< 12 h of admission) in terms of clinical outcomes. The primary outcome was the length of stay. RESULTS There were 98 and 201 patients who underwent elective and urgent biliary drainage, respectively. The median length of stay was 11 days in both groups (P = 0.52). The timing of ERCP was not associated with length of stay in the multivariable model (P = 0.52). Secondary outcomes including in-hospital mortality and recurrence of cholangitis were not different between the groups. CONCLUSIONS Elective biliary drainage was not associated with worse clinical outcomes of non-severe acute cholangitis as compared to urgent drainage. Further investigation is warranted to justify the elective drainage for non-severe cholangitis.
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27
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Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Association between early ERCP and mortality in patients with acute cholangitis. Gastrointest Endosc 2018; 87:185-192. [PMID: 28433613 DOI: 10.1016/j.gie.2017.04.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Acute cholangitis (AC) is associated with high mortality of up to 10%. The association between timing of ERCP and mortality in patients with AC remains unclear. The aim of this study was to investigate whether early ERCP within 24 hours was associated with improved survival. METHODS All patients who underwent ERCP at Odense University Hospital, Denmark, between March 2009 and September 2016 were identified using a prospective ERCP database. Clinical data were collected from medical records. Patients fulfilling the Tokyo Guidelines 2013 criteria and for whom a detailed review of medical records revealed evidence of AC were included. We investigated the association between ERCP within 24 hours and 30-day mortality using logistic regression analysis with adjustment for confounding factors. RESULTS A total of 4066 consecutive patients underwent ERCP during the study period, and 166 patients fulfilled the inclusion criteria. Forty-eight patients (29%) underwent ERCP within 24 hours from the time of hospitalization, and 118 patients (71%) underwent later ERCP. Patients undergoing ERCP within 24 hours were younger (medians: 65 vs 73 years; P = .01) and had a higher heart rate (medians: 95 vs 90 beats/minute; P = .02). Overall 30-day mortality was 16% (n = 27). Mortality was 8% (n = 4) among patients undergoing early ERCP and 19% (n = 23) among patients undergoing later ERCP (P = .10). After adjustment for confounding factors, performance of ERCP within 24 hours was associated with lower 30-day mortality (odds ratio, 0.23; 95% confidence interval, 0.05-0.95; P = .04). CONCLUSION Our results indicate that early ERCP within 24 hours is associated with lower 30-day mortality in patients with AC.
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Affiliation(s)
- Ming Tan
- Department of Medical Gastroenterology S, Odense University Hospital, Odense C, Denmark
| | | | - Stig B Laursen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense C, Denmark
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28
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Ely R, Long B, Koyfman A. The Emergency Medicine−Focused Review of Cholangitis. J Emerg Med 2018; 54:64-72. [DOI: 10.1016/j.jemermed.2017.06.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/10/2017] [Accepted: 06/29/2017] [Indexed: 02/07/2023]
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29
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Mohammad Alizadeh AH. Cholangitis: Diagnosis, Treatment and Prognosis. J Clin Transl Hepatol 2017; 5:404-413. [PMID: 29226107 PMCID: PMC5719198 DOI: 10.14218/jcth.2017.00028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/23/2017] [Accepted: 07/12/2017] [Indexed: 12/12/2022] Open
Abstract
Cholangitis is a serious life-threatening situation affecting the hepatobiliary system. This review provides an update regarding the clinical and pathological features of various forms of cholangitis. A comprehensive search was performed in the PubMed, Scopus, and Web of Knowledge databases. It was found that the etiology and pathogenesis of cholangitis are heterogeneous. Cholangitis can be categorized as primary sclerosing (PSC), secondary (acute) cholangitis, and a recently characterized form, known as IgG4-associated cholangitis (IAC). Roles of genetic and acquired factors have been noted in development of various forms of cholangitis. PSC commonly follows a chronic and progressive course that may terminate in hepatobiliary neoplasms. In particular, PSC commonly has been associated with inflammatory bowel disease. Bacterial infections are known as the most common cause for AC. On the other hand, IAC has been commonly encountered along with pancreatitis. Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis. Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography and endoscopic ultrasonography comprise three of the modalities that are frequently exploited as both diagnostic and therapeutic tools. Biliary drainage procedures using these methods is necessary for controlling the progression of cholangitis. Promising results have been reported for the role of antibiotic treatment in management of AC and PSC; however, immunosuppressive drugs have also rendered clinical responses in IAC. With respect to the high rate of complications, surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed.
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Temporal trends in utilization and outcomes of endoscopic retrograde cholangiopancreatography in acute cholangitis due to choledocholithiasis from 1998 to 2012. Surg Endosc 2017; 32:1740-1748. [DOI: 10.1007/s00464-017-5856-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/22/2017] [Indexed: 02/03/2023]
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Abstract
OBJECTIVES Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis. METHODS Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death. RESULTS ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events. CONCLUSIONS ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.
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Sarwar A, Zhou L, Chakrala N, Brook OR, Weinstein JL, Rosen MP, Ahmed M. The Relevance of Readmissions after Common IR Procedures: Readmission Rates and Association with Early Mortality. J Vasc Interv Radiol 2017; 28:629-636. [DOI: 10.1016/j.jvir.2017.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 01/14/2017] [Accepted: 01/14/2017] [Indexed: 01/07/2023] Open
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Park CS, Jeong HS, Kim KB, Han JH, Chae HB, Youn SJ, Park SM. Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients. Hepatobiliary Pancreat Dis Int 2016; 15:619-625. [PMID: 27919851 DOI: 10.1016/s1499-3872(16)60130-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute cholangitis in old people is a cause of mortality and prolonged hospital stay. We evaluated the effects of methods and timing of biliary drainage on the outcomes of acute cholangitis in elderly and very elderly patients. METHODS We analyzed 331 patients who were older than 75 years and were diagnosed with acute calculous cholangitis. They were admitted to our hospital from 2009 to 2014. Patients' demographics, severity grading, methods and timing of biliary drainage, mortality, and hospital stay were retrospectively obtained from medical records. Clinical parameters and outcomes were compared between elderly (75-80 years, n=156) and very elderly (≥81 years, n=175) patients. We analyzed the effects of methods [none, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage, or failure] and timing (urgent or early) of biliary drainage on mortality and hospital stay in these patients. RESULTS Acute cholangitis in older patients manifested as atypical symptoms characterized as infrequent Charcot's triad (4.2%) and comorbidity in one-third of the patients. Patients were graded as mild, moderate, and severe cholangitis in 104 (31.4%), 175 (52.9%), and 52 (15.7%), respectively. Urgent biliary drainage (≤24 hours) was performed for 80.5% (247/307) of patients. Very elderly patients tended to have more severe grades and were treated with sequential procedures of transient biliary drainage and stone removal at different sessions. Hospital stay was related to methods and timing of biliary drainage. Mortality was very low (1.5%) and not related to patient age but rather to the success or failure of biliary drainage and severity grading of the acute cholangitis. CONCLUSIONS The methods and timing used for biliary drainage and severity of cholangitis are the major determinants of mortality and hospital stay in elderly and very elderly patients with acute cholangitis. Urgent successful ERCP is mandatory for favorable prognosis in these patients.
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Affiliation(s)
- Chan Sun Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, 1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea.
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Karvellas CJ, Abraldes JG, Zepeda-Gomez S, Moffat DC, Mirzanejad Y, Vazquez-Grande G, Esfahani EK, Kumar A. The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock. Aliment Pharmacol Ther 2016; 44:755-66. [PMID: 27506331 DOI: 10.1111/apt.13764] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/06/2016] [Accepted: 07/23/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression. AIM To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock. METHODS Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011. RESULTS Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P < 0.001) and lower median serum lactate on admission (3.4 vs. 4.6 mmol/L, P < 0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8 h from shock, P < 0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 h, P < 0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P < 0.04 for all; c-statistic 0.896). CONCLUSIONS Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population.
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Affiliation(s)
- C J Karvellas
- Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada.,Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - J G Abraldes
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - S Zepeda-Gomez
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - D C Moffat
- Division of Gastroenterology, University of Manitoba, Winnipeg, MB, Canada
| | - Y Mirzanejad
- Section of Infectious Diseases, Surrey Memorial Hospital, Surrey, BC, Canada
| | - G Vazquez-Grande
- Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - E K Esfahani
- Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - A Kumar
- Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.,Section of Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
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Lee F, Ohanian E, Rheem J, Laine L, Che K, Kim JJ. Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis. Aliment Pharmacol Ther 2015; 42:212-20. [PMID: 25997554 DOI: 10.1111/apt.13253] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/09/2015] [Accepted: 04/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Predictors of organ failure and the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis are unclear. AIM To identify factors associated with persistent organ failure and assess the impact of early ERCP on outcomes in hospitalised patients with cholangitis. METHODS Consecutive hospitalised patients who received ERCP at two centres for cholangitis from 4/2005-3/2013 were retrospectively reviewed. Delayed ERCP was defined as ERCP ≥ 48 h after hospitalisation. Primary outcome was persistent organ failure at >48 h after hospitalisation (≥ 1.5 times rise in creatinine levels from baseline values to ≥ 1.5 mg/dL or need for dialysis, mechanical ventilation and/or hypotension requiring vasopressor). RESULTS 203 patients (mean age 59 ± 19 years) had ERCP for cholangitis: 115 with choledocholithiasis, 48 with other benign obstructions and 40 with malignant strictures. Forty-five (22%) patients had persistent organ failure at >48 h and 11 (5%) died. On multivariate analysis, Charlson Comorbidity Index >2 (OR = 4.6, 95% CI = 1.5-13.8), systemic inflammatory response syndrome (SIRS; OR = 3.2, 95% CI = 1.1-9.8), hypoalbuminemia (OR = 3.3, 95% CI = 1.4-7.9), bacteremia (OR = 2.8, 95% CI 1.3-6.2) and delayed ERCP(OR = 3.1, 95% CI: 1.4-7.0) were associated with persistent organ failure. Every 1-day delay in ERCP was associated with a 17% (95% CI = 5-29%) relative risk increase in persistent organ failure after adjusting for significant factors. CONCLUSIONS Delay in ERCP beyond 48 h was associated with persistent organ failure in hospitalised patients with acute cholangitis. Other factors included increased comorbidities, SIRS, hypoalbuminemia and bacteremia. Early ERCP performed within 48 h after presentation in patients with cholangitis may improve outcomes.
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Affiliation(s)
- F Lee
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - E Ohanian
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - J Rheem
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - L Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - K Che
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - J J Kim
- Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.,Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
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Kalaitzakis E, Toth E. Hospital volume status is related to technical failure and all-cause mortality following ERCP for benign disease. Dig Dis Sci 2015; 60:1793-800. [PMID: 25559758 DOI: 10.1007/s10620-014-3509-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 12/23/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Population-based data on hospital procedure volume and outcome of endoscopic retrograde cholangiopancreatography (ERCP) are limited. AIMS To investigate procedural failure, early re-admission, and all-cause mortality following ERCP performed due to benign disease and to examine their relation to hospital procedure volume. METHODS All patients with a first ERCP in 2005-2008 in Sweden were identified from the Swedish Hospital Discharge Registry. Data on indication, admission method, length of stay (LOS), and comorbid illness were extracted. Patients were linked to the Swedish Death and Cancer Registries. Factors associated with failed index ERCP, early re-admission, and all-cause mortality were identified by multiple logistic analyses. RESULTS Overall, 12,695 first ERCPs for benign disease were analyzed. The 30-day re-admission rate was 13 % and all-cause 30-day mortality 2.2 %. Failed index ERCP was more common in low-volume than high-volume institutions (p = 0.007). In logistic regression analysis, low hospital procedure volume was an independent predictor of failed index ERCP (odds ratio (OR) 2.72 vs. high), but not 30-day re-admission (p > 0.05). LOS was longer in cases of procedural failure (p < 0.001). All-cause 30-day mortality was independently related to low hospital ERCP volume (OR 1.41 vs. high) and failed ERCP (OR 5.65 vs. successful). CONCLUSION In this population-based cohort of first ERCPs due to benign disease, lower hospital ERCP volume was related to failed ERCP, which, in turn, was associated with longer LOS. Failed ERCP and lower hospital procedure volume were associated with poor survival, but not with early re-admission following index ERCP. These findings may have implications for service development.
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Affiliation(s)
- Evangelos Kalaitzakis
- Endoscopy Unit, Department of Gastroenterology, Skåne University Hospital, University of Lund, Malmö, Sweden,
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Voskuijl T, Hageman M, Ring D. Higher Charlson Comorbidity Index Scores are associated with readmission after orthopaedic surgery. Clin Orthop Relat Res 2014; 472:1638-44. [PMID: 24276857 PMCID: PMC3971213 DOI: 10.1007/s11999-013-3394-8] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 11/14/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Charlson Comorbidity Index (CCI) originally was developed to predict mortality within 1 year of hospital admission in patients without trauma. As it includes factors associated with medical and surgical complexities, it also may be useful as a predictive tool for hospital readmission after orthopaedic surgery, but to our knowledge, this has not been studied. QUESTIONS/PURPOSES We asked whether an increased score on the CCI was associated with (1) readmission, (2) an increased risk of surgical site infection or other adverse events, (3) transfusion risk, or (4) mortality after orthopaedic surgery. METHODS A total of 30,129 orthopaedic surgeries performed between 2008 and 2011 without any orthopaedic surgery in the preceding 30 days were analyzed. International Classification of Diseases, 9(th) Revision codes were used to identify diagnoses, procedures, surgery-related adverse events, surgical site infection, and comorbidities as listed in the updated and reweighted CCI. A total of 913 patients (3.0%) were readmitted within 30 days after discharge; in 393 (1.4%) patients adverse events occurred; 417 patients (1.4%) had a surgical site infection develop; 211 (0.7%) needed transfusions, and 56 (0.2%) died within 30 days after surgery. Ordinary least squares regression analyses were used to determine whether the CCI was associated with these outcomes. RESULTS The CCI accounted for 10% of the variation in readmissions. Every point increase in CCI score added an additional 0.45% risk in readmission for patients undergoing arthroplasty, 0.63% for patients undergoing trauma surgery, and 0.9% risk for patients undergoing spine surgery (all p < 0.01). The CCI was not associated with surgical site infection or other adverse events, but accounted for 8% of the variation in transfusion rate and 10% of the variation in mortality within 30 days of surgery. CONCLUSIONS The CCI can be used to estimate the risk of readmission after arthroplasty, hand and upper extremity surgery, spine surgery, and trauma surgery. It also can be used to estimate the risk of transfusion after arthroplasty, spine, trauma, and oncologic orthopaedic surgery and the risk of mortality after shoulder, trauma, and oncologic orthopaedic surgery. LEVEL OF EVIDENCE Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Timothy Voskuijl
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - Michiel Hageman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
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Parikh ND, Issaka R, Lapin B, Komanduri S, Martin JA, Keswani RN. Inpatient weekend ERCP is associated with a reduction in patient length of stay. Am J Gastroenterol 2014; 109:465-70. [PMID: 24145679 DOI: 10.1038/ajg.2013.362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/16/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) performed on the weekend requires significant effort from the endoscopist, nursing staff, and anesthesia services. These factors often result in delaying the procedure until the following Monday. No data exist on whether performing weekend ERCP reduces length of stay (LOS) and total cost to justify the additional physician and nursing burden. METHODS In this single tertiary academic center, institutional review board-approved study, we retrospectively reviewed all hospitalized patients in whom an ERCP had been completed from May 2010 to September 2011. Demographic and clinical information, procedure details as well as total hospitalization charges (USD) were compared between patients who had an ERCP either on the weekend or weekday holiday (WE ERCP) or Monday (MON ERCP). Statistical comparisons were made using χ(2) and Fischer's exact test. A logistic regression model adjusted for propensity scores (PSs) was used to estimate the risk in prolonged LOS and high total charges associated with WE ERCPs vs. MON ERCPs. RESULTS A total of 1,114 ERCP's were performed during the time period, 123 of which met inclusion criteria (52 WE, 71 MON). Mean patient age was 56.3±16.7 years (54.5% female, 60.2% Caucasian). There were no significant demographic differences between the two groups. The most common procedure indications were choledocholithiasis (34.9%) and elevated liver enzymes after liver transplantation (25.2%). The analysis showed a significantly decreased LOS (P=0.010) and a trend towards decreased cost (P=0.050) associated with WE ERCP. In the multivariate analysis adjusted for PS, WE ERCP had a significantly decreased odds ratio of LOS>3 days (odds ratio: 0.37 (0.16-0.85); P=0.019). CONCLUSIONS We demonstrated a significant decrease in LOS and a trend towards decrease in charges in patients who underwent weekend ERCP compared with delaying ERCP until Monday. Thus, health-care organizations should consider removing barriers to weekend inpatient ERCPs.
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Affiliation(s)
- Neehar D Parikh
- 1] Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA [2] Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachel Issaka
- Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brittany Lapin
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John A Martin
- Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Menon S. ERCP in cholangitis. Gastrointest Endosc 2014; 79:359. [PMID: 24433633 DOI: 10.1016/j.gie.2013.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 09/10/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Shyam Menon
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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Navaneethan U, Hammel JP, Parsi MA. Response. Gastrointest Endosc 2014; 79:359. [PMID: 24433632 DOI: 10.1016/j.gie.2013.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 10/01/2013] [Indexed: 12/11/2022]
Affiliation(s)
| | - Jeffrey P Hammel
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Mansour A Parsi
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Infectious and inflammatory diseases comprise some of the most common gastrointestinal disorders resulting in hospitalization in the United States. Accordingly, they occupy a significant proportion of the workload of the acute care surgeon. This article discusses the diagnosis, management, and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.
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