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Yamaguchi A, Wada K, Moriuchi R, Tao K, Konishi H, Tamaru Y, Kusunoki R, Kuwai T, Kouno H, Kohno H. Proportion of Neutrophils in White Blood Cells as a Useful Marker for Predicting Bacteremic Acute Cholangitis. Intern Med 2023; 62:2795-2802. [PMID: 36792196 PMCID: PMC10602826 DOI: 10.2169/internalmedicine.0945-22] [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: 09/02/2022] [Accepted: 01/04/2023] [Indexed: 02/16/2023] Open
Abstract
Objective A positive hemoculture in acute cholangitis is serious, but a blood culture result cannot be obtained at the initial diagnosis and so cannot be used for the severity assessment and decision-making concerning urgent/early biliary drainage. Accordingly, a predictor for bacteremia at the initial diagnosis of acute cholangitis would be particularly useful. We investigated the association between neutrophil proportions in white blood cell counts (%Neutro) and bacteremic acute cholangitis. Methods Of 166 patients with acute cholangitis who were diagnosed with the Tokyo Guidelines 2018/2013 from April 2015 to March 2017, a total of 94 underwent blood culture assessments and were divided into those with a positive hemoculture (n=48) and a negative hemoculture (n=46) and then compared. A receiver operating characteristic curve analysis was used to evaluate the predictive ability of %Neutro and other inflammatory markers. Results The %Neutro values were significantly higher in the positive hemoculture group than in the negative hemoculture group (91.7±4.0% vs. 82.5±9.0%, p<0.0001). A cut-off %Neutro value of 89.7% was strongly associated with bacteremia (area under the curve 0.86, sensitivity 77.1%, specificity 80.4%). A %Neutro of ≥89.7% was a predictor of a positive hemoculture in univariate (p<0.0001) and multivariate analyses (p<0.001). Patients with a %Neutro ≥89.7% needed early biliary drainage more frequently than others (30/46, 65.2% vs. 18/48, 37.5%, p=0.0063). Conclusion %Neutro is an independent predictor of bacteremia in patients with acute cholangitis and may contribute to decision-making concerning early biliary drainage.
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Affiliation(s)
- Atsushi Yamaguchi
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Kaoru Wada
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Riho Moriuchi
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Kanae Tao
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Hirona Konishi
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Yuzuru Tamaru
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Ryusaku Kusunoki
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Hirotaka Kouno
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
| | - Hiroshi Kohno
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Japan
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Shintani S, Inatomi O, Bamba S, Imai T, Tomozawa Y, Inoue A, Ota S, Takeda Y, Fujimoto T, Nishida A, Kutsumi H, Watanabe Y, Andoh A. Bile duct penetrating duodenal wall sign: a novel computed tomography finding of common bile duct stone impaction into duodenal major papilla. Jpn J Radiol 2023:10.1007/s11604-023-01406-1. [PMID: 36892785 DOI: 10.1007/s11604-023-01406-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/24/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE Impacted common bile duct stones cause severe acute cholangitis. However, the early and accurate diagnosis, especially iso-attenuating stone impaction, is still challenging. Therefore, we proposed and validated the bile duct penetrating duodenal wall sign (BPDS), which shows the common bile duct penetrating the duodenal wall on coronal reformatted computed tomography (CT), as a novel sign of stone impaction. METHODS Patients who underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to common bile duct stones were retrospectively enrolled. Stone impaction was defined by endoscopic findings as a reference standard. Two abdominal radiologists blinded to clinical information interpreted CT images to record the presence of the BPDS. The diagnostic accuracy of the BPDS to diagnose stone impaction was analyzed. Clinical data related to the severity of acute cholangitis were compared between patients with and without the BPDS. RESULTS A total of 40 patients (mean age 70.6 years; 18 female) were enrolled. The BPDS was observed in 15 patients. Stone impaction occurred in 13/40 (32.5%) cases. Overall accuracy, sensitivity, and specificity were 34/40 (85.0%), 11/13 (84.6%), and 23/27 (85.2%), respectively; 14/16 (87.5%), 5/6 (83.3%), and 9/10 (90.0%) for iso-attenuating stones; and 20/24 (83.3%), 6/7 (85.7%), and 14/17 (82.4%) for high-attenuating stones. Interobserver agreement of the BPDS was substantial (κ = 0.68). In addition, the BPDS was significantly correlated with the number of factors in the systemic inflammatory response syndrome (P = 0.03) and total bilirubin (P = 0.04). CONCLUSION The BPDS was a unique CT imaging finding to identify common bile duct stone impaction regardless of stone attenuation with high accuracy.
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Affiliation(s)
- Shuhei Shintani
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan.
| | - Shigeki Bamba
- Department of Endoscopy, Shiga University of Medical Science, Otsu, Japan
| | - Takayuki Imai
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Yuki Tomozawa
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Akitoshi Inoue
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Shinichi Ota
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan.,Department of Radiology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Yoshiya Takeda
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Takehide Fujimoto
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Atushi Nishida
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Hiromu Kutsumi
- Department of Center for Clinical Research, Shiga University of Medical Science, Otsu, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
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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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Biliary-Colonic Fistula Associated With High-Grade Biliary Stenosis From Errant Surgical Clip During Previous Biliary Surgery: Diagnosis and Treatment By ERCP. ACG Case Rep J 2021; 8:e00617. [PMID: 34124279 PMCID: PMC8189637 DOI: 10.14309/crj.0000000000000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
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Shinoura S, Tokushige A, Chinen K, Mori H, Kato S, Ueda S. Association between contrast-induced nephrotoxicity and contrast enhanced computed tomography followed by endoscopic retrograde cholangiopancreatography. Eur J Radiol 2020; 129:109074. [PMID: 32473539 DOI: 10.1016/j.ejrad.2020.109074] [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: 03/26/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine if endoscopic retrograde cholangiopancreatography (ERCP) performed within 72 h after contrast enhanced computed tomography (CECT) increases contrast-induced nephrotoxicity (CIN) risk in patients with abdominal complaints. METHOD This single-center retrospective cohort study included consecutive adult patients with abdominal complaints who underwent CECT between October 1, 2016, and June 30, 2019 at an emergency department (ED). CIN was diagnosed based on serum creatinine (SCr) level >0.5 mg/dL within 72 h after CECT or that increased >25 % compared to pre-CECT level. Logistic regression analysis was performed to determine independent risk factors for CIN, including age, sex, body mass index, comorbidities, medication, pre-CECT SCr level >1.5 mg/dL, and ERCP performed within 72 h after CECT. For persistent CIN, SCr level was obtained after 3 months at the earliest and compared to data obtained within 72 h after ERCP and CECT. RESULTS Of 1457 patients with CECT, 90 (6.2 %) underwent ERCP within 72 h after CECT and 93 (6.4 %) developed CIN. Multivariate analysis revealed that ERCP performed within 72 h after CECT (odds ratio, 3.31; 95 % confidence interval, 1.74, 6.29; p < 0.001) and pre-CECT SCr level >1.5 mg/dL (odds ratio, 9.86; 95 % confidence interval, 5.08, 19.2; p < 0.001) were independent risk factors for CIN. Of 93 patients with CIN, 10 (11 %) had persistent CIN. No specific factors were correlated with persistent CIN in the 3-month time frame. CONCLUSION ERCP performed within 72 h after CECT and pre-CECT SCr level >1.5 mg/dL are associated with CIN development.
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Affiliation(s)
- Susumu Shinoura
- School of Psychology and Healthcare Management at Akasaka, Department of Healthcare Management, International University of Health and Welfare, Minato, Tokyo, Japan; Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan; Department of Digestive Diseases, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Akihiro Tokushige
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | - Kenji Chinen
- Department of Digestive Diseases, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Hideki Mori
- Department of Digestive Diseases, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Shin Kato
- Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shinichiro Ueda
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan.
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Diaconescu B, Uranues S, Fingerhut A, Vartic M, Zago M, Kurihara H, Latifi R, Popa D, Leppäniemi A, Tilsed J, Bratu M, Beuran M. The Bucharest ESTES consensus statement on peritonitis. Eur J Trauma Emerg Surg 2020; 46:1005-1023. [PMID: 32303796 DOI: 10.1007/s00068-020-01338-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care. METHODS Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis. CONCLUSION This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.
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Affiliation(s)
- Bogdan Diaconescu
- Anatomy Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania.
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, P.R. China
| | - Mihaela Vartic
- Intensive Care Unit, Emergency Clinic Hospital Bucharest, Bucharest, Romania
| | - Mauro Zago
- General and Emergency Surgery Division, Department of Emergency and Robotic Surgery, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Hayato Kurihara
- Emergency Surgery and Trauma Section, Department of General Surgery, Humanitas Clinical and Research Hospital Head, Milan, Italy
| | - Rifat Latifi
- Westchester Medical Center, Valhalla, New York, USA
| | - Dorin Popa
- Surgery Department, University Hospital Linkoping, Linköping, Sweden
| | - Ari Leppäniemi
- Division of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Jonathan Tilsed
- Honorary Senior Lecturer Hull York Medical School, Chairman UEMS Division of Emergency Surgery, Heslington, UK
| | - Matei Bratu
- Anatomy Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania
| | - Mircea Beuran
- Surgery Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania
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Early biliary drainage is associated with favourable outcomes in critically-ill patients with acute cholangitis. GASTROENTEROLOGY REVIEW 2018; 13:16-21. [PMID: 29657606 PMCID: PMC5894448 DOI: 10.5114/pg.2018.74557] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 03/28/2017] [Indexed: 12/13/2022]
Abstract
Introduction Acute cholangitis (AC) is a clinical condition that requires prompt medical management with IV fluids, antibiotics, and biliary drainage (BD). The optimal timing for BD remains unclear. Aim To investigate the effect of biliary drainage timing on clinical outcomes in AC. Material and methods We conducted a retrospective study of patients with AC admitted to the ICU using the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Emergency department to BD time, hospital death, length of stay (LOS), and severity scores were extracted from the database. We investigated the effect of BD timing on mortality rates, persistent organ failure, and LOS. Results A total of 177 patients were included; 50% were males; median age was 75 years, in-hospital mortality was 9.6%, mean time-to-ERCP was 32 h (range: 0.42–229.6) with 76% meeting the Tokyo Guidelines (TG13) criteria for severe cholangitis, and median Simplified Acute Physiology Score II (SAPS II) was 42 (IQR: 33–51). Using 24 h as a cut-off, patients who underwent BD ≤ 24 h had less persistent organ failure (OR = 0.49; 95% CI: 0.26–0.96, p = 0.040), shorter ICU LOS (3.25 vs. 4.95 days, p = 0.040), shorter hospital LOS (7.71 vs. 13.57 days, p = 0.001), but no difference in either in-hospital mortality (OR = 0.47, 95% CI: 0.17–1.29, p = 0.146) or 28-day mortality (OR = 0.61, 95% CI: 0.24–1.53, p = 0.297). Conclusions In critically-ill patients with acute cholangitis, early biliary drainage ≤ 24 h is associated with less persistent organ failure and shorter length of stay but had no effect on patient survival.
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8
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Gravito-Soares E, Gravito-Soares M, Gomes D, Almeida N, Tomé L. Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model. Scand J Gastroenterol 2018; 53:329-334. [PMID: 29374984 DOI: 10.1080/00365521.2018.1430255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of Tokyo guidelines (TG) 2018/2013 (TG18/TG13) and predictors of poor prognosis in acute cholangitis. METHODS Retrospective 1-year study of consecutive hospital admissions for acute cholangitis. Prognosis was defined in terms of 30 d in-hospital mortality. RESULTS Of the 183 patients with acute cholangitis, diagnostic accuracy based on Charcot's triad, TG07 and TG18/TG13 was 67.8, 86.9 and 92.3% (p < .001), respectively. Regarding severity based on TG18/TG13, 30.6% of cases were severe. A poor prognosis was found in 10.9% of patients. After multivariate analysis, systolic blood pressure <90 mmHg (OR 11.010; p < .001), serum albumin <3 g/dL (OR 1.355; p = .006), active oncology disease (OR 3.818; p = .006) and malignant aetiology of obstructive jaundice (OR 2.224; p = .021) were independent predictors of poor prognosis. The discriminative ability of the model with these four variables was high (AUROC 0.842; p < .001), being superior to TG18/TG13 (AUROC 0.693; p = .005). CONCLUSIONS TG18/TG13 showed high diagnostic accuracy in acute cholangitis. Compared with TG18/TG13, the simplified severity model ≥2 allows easy selection of patients who will benefit from admission to the intensive care unit and early biliary decompression.
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Affiliation(s)
- Elisa Gravito-Soares
- a Gastroenterology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Marta Gravito-Soares
- a Gastroenterology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Dário Gomes
- a Gastroenterology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Nuno Almeida
- a Gastroenterology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Luís Tomé
- a Gastroenterology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,b Faculty of Medicine , University of Coimbra , Coimbra , Portugal
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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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10
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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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11
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Umefune G, Kogure H, Hamada T, Isayama H, Ishigaki K, Takagi K, Akiyama D, Watanabe T, Takahara N, Mizuno S, Matsubara S, Yamamoto N, Nakai Y, Tada M, Koike K. Procalcitonin is a useful biomarker to predict severe acute cholangitis: a single-center prospective study. J Gastroenterol 2017; 52:734-745. [PMID: 27783206 DOI: 10.1007/s00535-016-1278-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/14/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Procalcitonin is being increasingly used to diagnose and grade acute systemic bacterial infection at an early stage of disease onset. The aim of this prospective study was to evaluate the usefulness of procalcitonin for severity grading of acute cholangitis on patient admission. METHODS Patients with acute cholangitis were prospectively enrolled. The severity of acute cholangitis was graded on the basis of the 2013 Tokyo guidelines (Japanese Society of Hepato-Biliary-Pancreatic Surgery, 2013). We compared the ability of procalcitonin level on admission to predict moderate/severe (vs mild) or severe (vs mild/moderate) acute cholangitis with the abilities of white blood cell (WBC) count and C-reactive protein (CRP) level. RESULTS Two hundred thirteen patients were analyzed, and the severity of acute cholangitis was graded as mild, moderate, and severe in 108, 76, and 29 patients respectively. Procalcitonin level, WBC count, and CRP level all increased significantly according to the severity. In the receiver operating characteristic analyses, the area under the curve for procalcitonin for severe acute cholangitis was 0.90 [95% confidence interval (CI) 0.85-0.96] and was significantly greater than that for WBC (0.62; 95% CI 0.48-0.76) and that for CRP (0.70; 95% CI 0.60-0.80). The optimal cutoff value for procalcitonin for prediction of severe acute cholangitis was 2.2 ng/mL (sensitivity 0.97; specificity 0.73; accuracy 0.77). The areas under the curve for procalcitonin, WBC, and CRP for moderate/severe acute cholangitis were not significantly different. CONCLUSIONS Procalcitonin predicted severe acute cholangitis better than conventional biomarkers. Severe cases for which urgent biliary drainage is indicated might be identified on admission on the basis of the cutoff values for procalcitonin suggested in this study.
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Affiliation(s)
- Gyotane Umefune
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kaoru Takagi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Dai Akiyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeo Watanabe
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Ramchandani M, Pal P, Reddy DN. Endoscopic management of acute cholangitis as a result of common bile duct stones. Dig Endosc 2017; 29 Suppl 2:78-87. [PMID: 28425658 DOI: 10.1111/den.12848] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 02/08/2023]
Abstract
Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography (ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage (PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Partha Pal
- 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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Lan Cheong Wah D, Christophi C, Muralidharan V. Acute cholangitis: current concepts. ANZ J Surg 2017; 87:554-559. [DOI: 10.1111/ans.13981] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/23/2017] [Accepted: 02/26/2017] [Indexed: 02/06/2023]
Affiliation(s)
- David Lan Cheong Wah
- Department of Hepato-Pancreatic-Biliary Surgery; Austin Hospital; Melbourne Victoria Australia
| | - Christopher Christophi
- Department of Hepato-Pancreatic-Biliary Surgery; Austin Hospital; Melbourne Victoria Australia
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15
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Schneider J, Hapfelmeier A, Thöres S, Obermeier A, Schulz C, Pförringer D, Nennstiel S, Spinner C, Schmid RM, Algül H, Huber W, Weber A. Mortality Risk for Acute Cholangitis (MAC): a risk prediction model for in-hospital mortality in patients with acute cholangitis. BMC Gastroenterol 2016; 16:15. [PMID: 26860903 PMCID: PMC4746925 DOI: 10.1186/s12876-016-0428-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/29/2016] [Indexed: 01/14/2023] Open
Abstract
Background Acute cholangitis is a life-threatening bacterial infection of the biliary tract. Main focus of this study was to create a useful risk prediction model that helps physicians to assign patients with acute cholangitis into different management groups. Methods 981 cholangitis episodes from 810 patients were analysed retrospectively at a German tertiary center. Results Out of eleven investigated statistical models fit to 22 predictors, the Random Forest model achieved the best (cross-)validated performance to predict mortality. The receiver operating characteristics (ROC) curve revealed a mean area under the curve (AUC) of 91.5 %. Dependent on the calculated mortality risk, we propose to stratify patients with acute cholangitis into a high and low risk group. The mean sensitivity, specificity, positive and negative predictive value of the corresponding optimal cutpoint were 82.9 %, 85.1 %, 19.0 % and 99.3 %, respectively. All of these results emerge from nested (cross-)validation and are supposed to reflect the model’s performance expected for external data. An implementation of our risk prediction model including the specific treatment recommendations adopted from the Tokyo guidelines is available on http://www2.imse.med.tum.de:3838/. Conclusion Our risk prediction model for mortality appears promising to stratify patients with acute cholangitis into different management groups. Additional validation of its performance should be provided by further prospective trails.
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Affiliation(s)
- Jochen Schneider
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Technische Universität München, München, Germany.
| | - Sieglinde Thöres
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Andreas Obermeier
- Klinik für Orthopädie, Labor für Infektionsforschung, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Christoph Schulz
- Institut für klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Dominik Pförringer
- I. Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Simon Nennstiel
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Christoph Spinner
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Hana Algül
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Andreas Weber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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Tabibian JH, Yang JD, Baron TH, Kane SV, Enders FB, Gostout CJ. Weekend Admission for Acute Cholangitis Does Not Adversely Impact Clinical or Endoscopic Outcomes. Dig Dis Sci 2016; 61:53-61. [PMID: 26391268 DOI: 10.1007/s10620-015-3853-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/17/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute cholangitis (AC) requires prompt diagnosis and treatment for optimal management. AIMS To examine whether a putative "weekend effect" impact outcomes of patients hospitalized for AC. METHODS We conducted a retrospective study of patients admitted with AC between 2009 and 2012. After excluding those not meeting Tokyo consensus criteria for AC, the cohort was categorized into weekend (Saturday-Sunday) and weekday (Monday-Friday) hospital admission and endoscopic retrograde cholangiography (ERC) groups. Primary outcome was length of stay (LOS); secondary outcomes included ERC performance, organ failure, and mortality. Groups were compared with Chi-square and t tests; predictors of LOS were assessed with linear regression. RESULTS The cohort consisted of 181 patients (mean age 63.1 years, 62.4 % male). Choledocholithiasis was the most common etiology of AC (29.4 %). Fifty-two patients (28.7 %) were admitted on a weekend and 129 (71.3 %) on a weekday. One hundred forty-one patients (78 %) underwent ERC, of which 120 (85 %) were on a weekday. There were no significant differences in baseline characteristics, LOS, proportion undergoing ERC, time to ERC, organ failure, or mortality between weekend and weekday admission groups. Similarly, there were no significant differences between weekend and weekday ERC groups. In multivariate analyses, international normalized ratio (p < 0.01) and intensive care unit triage (p < 0.01) were independent predictors of LOS, whereas weekend admission (p = 0.23) and weekend ERC (p = 0.74) were not. CONCLUSIONS Weekend admission and weekend ERC do not negatively impact outcomes of patients hospitalized with acute cholangitis at a tertiary care center. Further studies, particularly in centers with less weekend resources or staffing, are indicated.
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Affiliation(s)
- James H Tabibian
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.,Center for Endoscopic Education, Innovation, and Training, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.,Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Felicity B Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Christopher J Gostout
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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Nishino T, Hamano T, Mitsunaga Y, Shirato I, Shirato M, Tagata T, Shimada M, Yoshida S, Mitsunaga A. Clinical evaluation of the Tokyo Guidelines 2013 for severity assessment of acute cholangitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 21:841-9. [PMID: 25410528 DOI: 10.1002/jhbp.189] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We evaluated the severity assessment criteria for acute cholangitis (AC) of the Tokyo Guidelines 2013 (TG13) and developed a scoring system for predicting the need for urgent/early biliary drainage. METHODS We retrospectively reviewed 66 AC cases prospectively managed based on the TG07 and divided into an urgent/early biliary drainage group (n = 30) and elective biliary drainage group (n = 36). RESULTS There were 26 mild, 27 moderate, and 13 severe cases based on the TG13. The TG13 assessment in 12 of the 17 cases requiring early biliary drainage based on the TG07 was moderate, but underestimated the other five cases as mild AC. When five predictors (blood urea nitrogen >20 mg/dL, SIRS presence, platelet count <120 000/μL, serum albumin level <3.0 g/dL, age ≥75 years old) were used to devise a scoring system, the receiver-operator characteristic curve of the scores showed good test performance for predicting the need for urgent/early biliary drainage. The area under the curve (AUC) was 0.95 and higher than the TG13 AUC (0.80). CONCLUSIONS The TG13 is practical, but some AC cases requiring urgent/early biliary drainage were underestimated as mild AC. The scoring system allows identification of high-risk AC patients and will improve the TG13.
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Affiliation(s)
- Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Medical Center, 477-96 Owada-Shinden, Yachiyo, Chiba, 276-8542, Japan.
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Huang SY, Philip A, Richter MD, Gupta S, Lessne ML, Kim CY. Prevention and management of infectious complications of percutaneous interventions. Semin Intervent Radiol 2015; 32:78-88. [PMID: 26038616 DOI: 10.1055/s-0035-1549372] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.
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Affiliation(s)
- Steven Y Huang
- Department of Interventional Radiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Asher Philip
- Department of Interventional Radiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Michael D Richter
- Department of Interventional Radiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sanjay Gupta
- Department of Interventional Radiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Mark L Lessne
- Vascular and Interventional Specialists of Charlotte Radiology, Charlotte, North Carolina
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
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Sun G, Han L, Yang YS, Linghu EQ, Li W, Cai FC, Kong JY, Wang XD, Meng JY, Du H, Wang HB, Huang QY, Hyder Q, Zhang XL. Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int 2013; 12:400-7. [PMID: 23924498 DOI: 10.1016/s1499-3872(13)60062-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcot's triad (P<0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and 15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.
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Affiliation(s)
- Gang Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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Navaneethan U, Gutierrez NG, Jegadeesan R, Venkatesh PGK, Butt M, Sanaka MR, Vargo JJ, Parsi MA. Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis. Gastrointest Endosc 2013; 78:81-90. [PMID: 23528654 DOI: 10.1016/j.gie.2013.02.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 02/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Readmission to the hospital within 30 days of discharge (30-day readmission rate) is used as a quality measure. OBJECTIVE To investigate the incidence and factors that contribute to readmissions in patients with acute cholangitis. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and ERCP. INTERVENTION ERCP MAIN OUTCOME MEASUREMENTS Incidence and variables associated with 30-day readmission and 1-year mortality. RESULTS ERCP was successful in 98.8% of patients during the index admission. The 30-day readmission rate was 22.0%. Recurrence of cholangitis was the most common etiology for readmissions (37.8%). Readmission within 30 days was independently associated with failed ERCP or ERCP delayed for >48 hours (odds ratio [OR] 2.47; 95% confidence interval [CI], 1.01-6.07), development of any after-ERCP adverse event (OR 11.0; 95% CI, 3.06-39.30), and the etiology of cholangitis (etiologies not related to stones) (OR 3.3; 95% CI, 1.17-9.18). Every 1-point increase in the Charlson Comorbidity Index score (OR, 1.33; 95% CI, 1.05-1.69) was associated significantly with 1-year mortality. In unadjusted analysis, 30-day readmission after ERCP was associated significantly with 1-year mortality (OR, 2.86; 95% CI, 1.16-7.07). This association, however, was not present after adjustment for other covariates. LIMITATIONS Retrospective study. CONCLUSION Delays in performing ERCP during the index admission, development of after-ERCP adverse events, and etiology of cholangitis not related to stones increased the risk of 30-day readmissions.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Jang SE, Park SW, Lee BS, Shin CM, Lee SH, Kim JW, Jeong SH, Kim N, Lee DH, Park JK, Hwang JH. Management for CBD stone-related mild to moderate acute cholangitis: urgent versus elective ERCP. Dig Dis Sci 2013; 58:2082-7. [PMID: 23456495 DOI: 10.1007/s10620-013-2595-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 02/06/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is no doubt that urgent biliary decompression needs to be done in case of severe acute cholangitis. However, it remains to be determined how early biliary decompression should be performed and elective intervention would be comparable to urgent intervention, in case of mild to moderate choledocholithiasis associated cholangitis. METHODS One hundred ninety-five patients were enrolled who were diagnosed with mild to moderate cholangitis with common bile duct (CBD) stones between January 2006 and August 2010. They were divided into two groups according to door to intervention time, and urgent (≤24 h, n = 130) versus elective (>24 h, n = 82). Primary outcomes of this study were technical success rate (CBD stones removal) and clinical success rate (improvement of cholangitis) between the two groups. Hospital stay and intervention-related complications were also evaluated. RESULTS There was no statistically significant difference in technical, clinical success rate and intervention-related complications between the urgent and elective groups (P = 0.737, 0.285, 0.398, respectively). Patients in the urgent group had significantly shorter hospitalization than in the elective group (6.8 vs. 9.2 days, P < 0.001), and furthermore, intervention to discharge time was also significantly shorter by 1.1 days in the urgent group (P = 0.035). In terms of laboratory parameters, initial CRP level was the only factor correlated with hospital stay and intervention to discharge time. CONCLUSIONS This study demonstrates that urgent ERCP would be recommended in the management of patients with CBD stone-related mild to moderate acute cholangitis because of the advantage of short hospital stay and intervention to discharge time.
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Affiliation(s)
- Sang Eon Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seoungnam-si, Gyeonggi-do 463-707, South Korea
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Lee BS, Hwang JH, Lee SH, Jang SE, Jang ES, Jo HJ, Shin CM, Park YS, Kim JW, Jung SH, Kim N, Lee DH, Lee JK, Ahn S. Risk factors of organ failure in patients with bacteremic cholangitis. Dig Dis Sci 2013. [PMID: 23179153 DOI: 10.1007/s10620-012-2478-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bacteremic cholangitis carries a high mortality rate of up to 10 % in relation to organ failure (OF), including septic shock. AIM The purpose of this study was to elucidate predictive factors for OF in bacteremic cholangitis. METHODS A retrospective review of all patients diagnosed with acute cholangitis and proven bacteremia from 2003 to 2011 was performed. Comprehensive clinical and laboratory data of 211 patients were analyzed. RESULTS There were 42 cases (19.9 %) of OF and 5 deaths (2.4 %). In the multivariate logistic regression analysis, significant predictive factors for OF were successful biliary decompression, presence of extended-spectrum beta-lactamase organism (ESBL), higher total bilirubin, and higher blood urea nitrogen (BUN) level at admission with odds ratios (ORs) of 0.129, 6.793, 1.148, and 1.089, respectively. Subgroup analysis of 165 patients who underwent biliary decompression before an event (with OF: 20, without OF: 145) was performed to elucidate the risk factors for organ failure even after successful biliary drainage. Variables significantly associated with OF included ESBL and BUN (OR = 4.123 and 1.177, respectively). We developed a scoring system with regression coefficient of each significant variable. The organ failure score was calculated using the following equation: (1.4 × ESBL) + (0.2 × BUN). This scoring system for predicting OF was highly sensitive (85.0 %) and specific (83.4 %). CONCLUSIONS Biliary decompression, ESBL, total bilirubin, and BUN are prognostic determinants in patients with bacteremic cholangitis. An organ failure scoring system may allow clinicians to identify groups with poor prognosis even after successful biliary decompression.
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Affiliation(s)
- Ban Seok Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Endoscopic treatment of the choledocholithiasis--effectiveness, safety and limitations of the method. POLISH JOURNAL OF SURGERY 2013; 84:333-40. [PMID: 22935454 DOI: 10.2478/v10035-012-0056-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is accepted referred method of treatment of the choledocholithiasis. THE AIM OF THE STUDY Evaluation of efficacy and safety of the endoscopic treatment of the biliary tract stones. MATERIAL AND METHODS Results of 3309 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) carried out in Division of Endoscopy of the General Surgery Department in the period 2000 - 2010. The retrospective analysis of the indications, process, findings and final results of 1698 ERCP and Endoscopic Sphincterotomy (ES) was performed with intention to treat of the biliary tract stones. RESULTS The 883 (52%)patients with coexisted gall-bladder and biliary tract stones were the principal group. The second group included 580 (34.2%) patients with residual choledocholithiasis after cholecystectomy and biliary tract surgery. Moreover ERCP, ES and endoscopic evacuation of biliary stones have been urgently carried out in 159 (9.4%) cases with acute biliary pancreatitis. Lastly ERCP with re-sphincterotomy and removal of the stones was performed in 75 (4.4%) patients with recurrent choledocholithiasis. The procedure was effective in 1561 (92%) patients. When removal of the stones was not possible, decompression of the biliary tract by implantation of the plastic stent was done in 63 (3.7%) cases. Ineffective procedure was noted in 74 (4.3%) patients. The most commonly observed complication was acute pancreatitis. Because of: post ES bleeding, acute haemmorhagic and necrotic pancreatitis, impacted Dormia basket and peripapillary duodenal perforation 10 patients (0.5%) had to be operated. Two patients (0.1%) died. CONCLUSIONS 1. Endoscopic treatment of choledocholithiasis is highly effective but risk factors of complications with urgency an intensive conservative management and surgical intervention have to be considered. 2. After ES, if surgical evacuation of the stones have to be carry out, post operative biliary tract drainage (by T tube) is not necessary.
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New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:548-56. [PMID: 22825491 PMCID: PMC3429782 DOI: 10.1007/s00534-012-0537-3] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Tokyo Guidelines for the management of acute cholangitis and cholecystitis were published in 2007 (TG07) and have been widely cited in the world literature. Because of new information that has been published since 2007, we organized the Tokyo Guidelines Revision Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines (TG13). METHODS/MATERIALS We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was suspected. The cases were collected from multiple tertiary care centers in Japan. The 'gold standard' for acute cholangitis in this study was that one of the three following conditions was present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or (3) remission was achieved by antibacterial therapy alone, in patients in whom the only site of infection was the biliary tree. Comparisons were made for the validity of each diagnostic criterion among TG13, TG07 and Charcot's triad. RESULTS The major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from 82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of Charcot's triad was only 26.4 % but the specificity was 95.6 %. However, the false positive rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading, Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors which were derived from evidence presented recently in the literature. The factors chosen allow severity assessment to be performed soon after diagnosis of acute cholangitis. CONCLUSION TG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.
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Tsuyuguchi T, Sugiyama H, Sakai Y, Nishikawa T, Yokosuka O, Mayumi T, Kiriyama S, Yokoe M, Takada T. Prognostic factors of acute cholangitis in cases managed using the Tokyo Guidelines. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:557-65. [PMID: 22825492 DOI: 10.1007/s00534-012-0538-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE In 2007, the Tokyo Guidelines (TG07) working group established diagnostic criteria for assessment of the severity of acute cholangitis. This study aimed to analyze outcomes and identify predictors of mortality in patients with acute cholangitis managed according to the TG07. METHODS In this study, 215 consecutive cases of acute cholangitis were reviewed. Risk factors associated with mortality or refractory cholangitis, which is defined on the basis of prolonged hospitalization (>28 days) or disease resulting in fatality, were examined using multivariate logistic regression analysis. RESULTS There were 52, 133, and 30 cases of mild, moderate, and severe cholangitis, respectively. The overall mortality rate was 4.2 % (9/215). Mortality rates in patients with mild, moderate, and severe cholangitis were 0, 2.3, and 20.0 %, respectively (moderate vs. severe, p = 0.001). Multivariate analysis showed that serum albumin levels ≤2.8 g/dl and PT-INR >1.5 were significant predictors of mortality. There were 57 patients (26.5 %) with refractory cholangitis. Multivariate analysis showed that serum albumin level ≤2.8 g/dl, PT-INR >1.5, etiology and inpatient status were significant predictors of refractory cholangitis. CONCLUSIONS The TG07 severity assessment criteria for acute cholangitis were significantly predictive of mortality. Hypoalbuminemia is an important risk factor in addition to organ dysfunction.
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Affiliation(s)
- Toshio Tsuyuguchi
- Department of Gastroenterology and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
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Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, Moore FA, Velmahos G, Coimbra R, Ivatury R, Peitzman A, Koike K, Leppaniemi A, Biffl W, Burlew CC, Balogh ZJ, Boffard K, Bendinelli C, Gupta S, Kluger Y, Agresta F, Di Saverio S, Wani I, Escalona A, Ordonez C, Fraga GP, Junior GAP, Bala M, Cui Y, Marwah S, Sakakushev B, Kong V, Naidoo N, Ahmed A, Abbas A, Guercioni G, Vettoretto N, Díaz-Nieto R, Gerych I, Tranà C, Faro MP, Yuan KC, Kok KYY, Mefire AC, Lee JG, Hong SK, Ghnnam W, Siribumrungwong B, Sato N, Murata K, Irahara T, Coccolini F, Lohse HAS, Verni A, Shoko T. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013; 8:3. [PMID: 23294512 PMCID: PMC3545734 DOI: 10.1186/1749-7922-8-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/02/2013] [Indexed: 12/11/2022] Open
Abstract
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.
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Affiliation(s)
| | - Pierluigi Viale
- Clinic of Infectious Diseases, Department of Internal Medicine Geriatrics and Nephrologic Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Emergency Surgery, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- Department of General Surgery, Ospedali Riuniti, Bergamo, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | | | - George Velmahos
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston, MA, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Andrew Peitzman
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Walter Biffl
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | - Zsolt J Balogh
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Ken Boffard
- Department of Surgery, Charlotte Maxeke Johannesburg Hospital University of the Witwatersrand, Johannesburg, South Africa
| | - Cino Bendinelli
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Sanjay Gupta
- Department of Surgery, Govt Medical College and Hospital, Chandigarh, India
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Imtiaz Wani
- Department of Digestive Surgery Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Escalona
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Carlos Ordonez
- Department of Surgery, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas - University of Campinas, Campinas, Brazil
| | | | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital /UMBAL/ St George Plovdiv, Plovdiv, Bulgaria
| | - Victor Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Noel Naidoo
- Department of Surgery, Port Shepstone Hospital, Kwazulu Natal, South Africa
| | - Adamu Ahmed
- Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
| | - Ashraf Abbas
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | | | | | - Rafael Díaz-Nieto
- Department of General and Digestive Surgery, University Hospital, Malaga, Spain
| | - Ihor Gerych
- Department of General Surgery, Lviv Emergency Hospital, Lviv, Ukraine
| | | | - Mario Paulo Faro
- Division of General and Emergency Surgery, Faculdade de Medicina da Fundação do ABC, São Paulo, Santo André, Brazil
| | - Kuo-Ching Yuan
- Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | - Jae Gil Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Wagih Ghnnam
- Wagih Ghnnam, Department of Surgery, Khamis Mushayt General Hospital, Khamis Mushayt, Saudi Arabia
| | - Boonying Siribumrungwong
- Boonying Siribumrungwong, Department of Surgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Norio Sato
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kiyoshi Murata
- Department of Acute and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Emergency and Critical Care Center of Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Alfredo Verni
- Department of Surgery, Cutral Co Clinic, Neuquen, Argentina
| | - Tomohisa Shoko
- The Shock Trauma and Emergency Medical Center, Matsudo City Hospital, Chiba, Japan
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Qin YS, Li QY, Yang FC, Zheng SS. Risk factors and incidence of acute pyogenic cholangitis. Hepatobiliary Pancreat Dis Int 2012; 11:650-4. [PMID: 23232638 DOI: 10.1016/s1499-3872(12)60240-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute cholangitis varies from mild to severe form. Acute suppurative cholangitis (ASC), the severe form of acute cholangitis, is a fatal disease and requires urgent biliary decompression. Which patients are at a high risk of ASC and need emergency drainage is still unclear. The present study aimed to identify the factors for determining early-stage ASC and distinguishing ASC from acute cholangitis. METHODS We analyzed 359 consecutive patients with acute cholangitis who had been admitted to the First Affiliated Hospital, Zhejiang University School of Medicine from January 2004 to May 2011. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was carried out in all patients to decompress or clear the stones by experienced endoscopists. Clinical and therapeutic data were collected, and univariate and multivariate analyses were performed to identify the potential risk factors of ASC. RESULTS Of the 359 patients, 1 was excluded because of failure of ERCP drainage. Of the remaining 358 patients with an average age of 62.7 years (range 17-90), 162 were diagnosed with ASC, and 196 with non-ASC. ENBD catheters were placed in 343 patients (95.8%), of whom 182 patients had stones removed at the same time, and plastic stent was placed in 25 patients (7.0%). Clinical conditions were improved quickly after emergency biliary drainage in all patients. Complications were identified in 11 patients (3.1%): mild pancreatitis occurred in 8 patients and hemorrhage in 3 patients. There was no mortality. Univariate analysis showed that several variables were associated with ASC: age, fever, decreased urine output, hypotension, tachycardia, abnormal white blood cell count (WBC), low platelet, high C reactive protein (CRP), and duration of the disease. Multivariate analysis revealed that advanced age, hypotension, abnormal WBC, high CRP, and duration of the disease were independent risk factors for ASC. CONCLUSIONS This study demonstrates that advanced age, hypotension, abnormal WBC, high CRP, and long duration of antibiotic therapy are significantly associated with ASC. We recommend decompression by ERCP should be carried out in patients as early as possible.
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Affiliation(s)
- Yun-Sheng Qin
- Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Mok SRS, Mannino CL, Malin J, Drew ME, Henry P, Shivaprasad P, Milcarek B, Elfant AB, Judge TA. Does the urgency of endoscopic retrograde cholangiopancreatography (ercp)/percutaneous biliary drainage (pbd) impact mortality and disease related complications in ascending cholangitis? (deim-i study). JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:161-167. [PMID: 23687602 PMCID: PMC3655387 DOI: 10.4161/jig.23744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/09/2012] [Accepted: 10/31/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Tokyo Guidelines have greatly impacted the management of ascending cholangitis. Though ERCP is the favored modality for biliary decompression, no evidence exists for the timing of ERCP. The DEIM-I study set out to determine if the time from patient presentation to biliary decompression impacted in hospital all cause mortality in ascending cholangitis. METHOD DEIM-I cohort study was a single-blinded and consisted of 250 subjects with moderate to severe ascending cholangitis who underwent ERCP/PBD. Subjects were randomized into quartiles based upon time from presentation until ERCP/PBD. The primary outcome utilized logistic regression to estimate relative risk (RR) of all cause, in hospital mortality with time to procedure as the predictive covariate. Secondary outcomes were analyzed using multivariate logistic regression and included; multiple organ failure (MOF), sepsis, systemic inflammatory response syndrome (SIRS), surgical incidence, hospital readmission and length of stay (LOS). RESULTS The risk for hospital mortality was significantly less when biliary drainage was performed within 11 h, compared to >42 h (RR 0.34, 95%CI 0.12 to 0.99, p=0.049). Hospital readmission was lower in subjects who underwent biliary decompression less than 11 h, when compared to those greater than 22 h. Subjects who underwent biliary decompression within 21 h had significant higher risk for surgery compared to those 22-42 h. CONCLUSION The relative risk of all cause in hospital mortality was lower in subjects who underwent biliary decompression in under 11 h compared to greater than 42 h.
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Affiliation(s)
- Shaffer R S Mok
- Department of Internal Medicine, Division of Internal Medicine at Cooper University Hospital of Rowan University, Camden, NJ
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29
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Proposed new simple scoring system to identify indications for urgent ERCP in acute cholangitis based on the Tokyo Guidelines. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:698-706. [DOI: 10.1007/s00534-011-0488-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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30
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Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative cholangitis caused by common bile duct stones? Gut Liver 2010; 4:363-7. [PMID: 20981214 DOI: 10.5009/gnl.2010.4.3.363] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Accepted: 07/23/2010] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND/AIMS Acute suppurative cholangitis (ASC), a severe form of acute cholangitis, is a life-threatening condition that must be treated with appropriate and timely management. The purpose of this study was to identify the factors that predispose patients to ASC. METHODS We retrospectively investigated 181 patients (100 men, 81 women; age, 70.66±7.38 years, mean±SD) who were admitted to Wonkwang University Hospital between January 2005 and June 2007 for acute cholangitis with common bile duct (CBD) stones. All patients underwent endoscopic retrograde cholangiopancreatogram to remove the stones. Variables and factors that could be assessed upon admission were analyzed to identify the risk factors for the development of ASC. RESULTS Of the 181 patients, 44 (24.3%) presented with ASC. On multivariate analysis, the followings were found to be independent risk factors for the development of ASC: impacted common bile duct stone (p=0.010), current smoker status (p=0.008), advanced age (>70 years; p=0.002), and gallstone (p=0.016). The most commonly isolated organisms in bile culture were Enterococcus species, Escherichia coli, and Klebsiella species. CONCLUSIONS Impacted bile-duct stones, current smoking, advanced age, and gallstones were identified as independent risk factors for the development of ASC in patients with CBD stones. These results suggest that emergency biliary drainage is beneficial in patients with these risk factors.
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Affiliation(s)
- Dong Han Yeom
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
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31
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Abstract
Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.
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Affiliation(s)
- John G Lee
- University of California Irvine Medical Center, 101 The City Drive, Building 53, Room 113, Orange, CA 92868, USA.
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Abstract
BACKGROUND Multifactor prognostic scoring systems have been developed for acute pancreatitis to identify those patients with a potentially poor prognosis. A similar system for patients with acute cholangitis is still lacking. GOALS To identify common clinical, biochemical, and etiologic variables that can be used to predict mortality and the need for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis. STUDY A retrospective study of 108 patients with acute cholangitis was performed at a single center. Univariate analysis and logistic regression were used to identify variables that were significantly associated and predictive of mortality and need for early ERCP. RESULTS Univariate analysis identified 18 variables significantly associated with mortality and 15 variables that predicted the need for early ERCP. Through logistic regression total bilirubin (P<0.01), partial prothrombin time (P<0.01), and presence of a liver abscess (P<0.01) were found to be significant in predicting mortality. Alanine aminotransferase (P<0.01) and white blood cell count (P<0.01) were determined to be predictive of a need for early ERCP. The scoring systems for predicting mortality (93.9%, 80.7%) and early ERCP (98%, 91%) were both highly sensitive and specific, respectively. CONCLUSIONS Acute cholangitis is a disease that presents with varying severity. We report a scoring system that can be used to identify patients at high risk of early mortality and those that may benefit from earlier ERCP.
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Rosing DK, De Virgilio C, Nguyen AT, Masry ME, Kaji AH, Stabile BE. Cholangitis: Analysis of Admission Prognostic Indicators and Outcomes. Am Surg 2007. [DOI: 10.1177/000313480707301003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute cholangitis is a life-threatening complication of biliary obstruction that is exacerbated by delays in diagnosis and treatment. Since the introduction of endoscopic retrograde cholangiography and endoscopic therapeutic modalities, few investigations have addressed admission prognostic indicators of adverse outcomes. A retrospective review of all patients with a diagnosis of acute cholangitis from 1995 to 2005 was performed. Primary endpoints were organ failure and death. One-hundred and seventeen patients met criteria for acute cholangitis. Only 49 (42%) had Charcot's triad and 3 (3%) had Reynolds’ pentad. One-hundred and four (89%) patients underwent biliary decompression, of which 79 (76%) were treated by endoscopic methods. There were 29 (25%) cases of organ failure and 9 (8%) deaths. The admission white blood cell (WBC) count ( P = 0.0003) and total bilirubin (TBili) ( P = 0.04) were statistically significant predictors of organ failure or death. With an admission of WBC ≥ 20,000 cells/mm3, the sensitivity, specificity, positive predictive value, and negative predictive value for organ failure and death were 50 per cent, 92 per cent, 63 per cent, and 88 per cent, respectively. A TBili of ≥10 mg/dL had sensitivity, specificity, positive predictive value, and negative predictive value of 56 per cent, 85 per cent, 21 per cent, and 96 per cent, respectively for predicting death. Admission WBC ≥ 20,000 cells/mm3 and TBili ≥ 10 mg/dL are selective predictors of adverse outcomes in acute cholangitis.
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Affiliation(s)
- David K. Rosing
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Christian De Virgilio
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Alex T. Nguyen
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Monica El Masry
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Amy H. Kaji
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Bruce E. Stabile
- Departments of Surgery and Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Torrance, California
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Kawai K, Hiramatsu T, Kobayashi R, Takabayashi N, Ishihara Y, Ohata K, Niwa H, Yasuike J, Tanaka H, Kimura M, Shindoh J. Coagulation disorder as a prognostic factor for patients with colorectal perforation. J Gastroenterol 2007; 42:450-5. [PMID: 17671759 DOI: 10.1007/s00535-007-2027-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 02/07/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although sepsis after surgery for colorectal perforation frequently results in severe coagulation disorders and consequent death of the patient, the correlation between coagulation abnormalities and postoperative mortality of colorectal perforation has not been clarified. METHODS The medical records of 101 consecutive patients receiving surgery for colorectal perforations between January 1994 and July 2006 were retrospectively reviewed. The abnormalities of preoperative laboratory data reflecting coagulation disorders and other possible risk factors were analyzed by univariate and multivariate analysis. RESULTS Prolonged prothrombin time and activated partial thromboplastin time significantly correlated with a poor prognosis (both P < 0.001). Among the several risk factors analyzed, only the presence of coagulation disorders was an independent predictive factor of postoperative mortality. CONCLUSIONS Prolonged prothrombin time and activated partial thromboplastin time are useful prognostic factors for predicting the surgical outcome for patients with colorectal perforation.
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Affiliation(s)
- Kazushige Kawai
- Department of Surgery, Yaizu City Hospital, 1000 Dobara, Yaizu, Japan
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Daher Filho PF, Campos TD, Kuryura L, Belotto M, Silva RA, Pacheco Júnior AM. Avaliação de complicações relacionadas à CPRE em pacientes com suspeita de coledocolitíase. Rev Col Bras Cir 2007. [DOI: 10.1590/s0100-69912007000200009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJETIVO: Determinar os fatores preditivos de complicações da colangio-pancreatografia retrógrada endoscópica (CPRE) nos doentes com suspeita diagnóstica de coledocolitíase. MÉTODO: Os dados foram coletados retrospectivamente durante o período de agosto de 1999 a janeiro 2005. Foram incluídos os doentes com suspeita diagnóstica de coledocolitíase submetidos à CPRE internados na Santa Casa de Misericórdia de São Paulo. Os doentes com neoplasia de vias biliares ou de pâncreas foram excluídos. Foram avaliados: o sucesso do procedimento, as complicações como pancreatite, sangramento, colangite, perfuração, vômitos, hiperamilasemia e em quais situações estas complicações se desenvolveram. Os testes t de Student, Qui-quadrado e o teste exato de Fisher foram empregados para análise estatística, considerando-se p< 0,05 como significativo. RESULTADOS: Cento e setenta oito doentes foram incluídos, sendo 52 homens e 126 mulheres com média etária de 54,3 + 19,3. A CPRE confirmou o diagnóstico de coledocolitíase em 124 doentes (69,7%), obtendo sucesso no tratamento endoscópico em 92 casos (74,2%). As complicações foram detectadas em 19 doentes (10,7%), com seis casos de pancreatite aguda (3,4%), quatro (2,2%) que tiveram sangramento durante o procedimento endoscópico, dois (1,1%) doentes que desenvolveram colangite, um (0,6%) com perfuração duodenal, quatro (2,2%) com vômitos sem pancreatite e dois (1,1%) com complicações clinicas. A cateterização do ducto pancreático durante a realização do procedimento endoscópico esteve associada com o desenvolvimento de pancreatite aguda (p=0,004). CONCLUSÃO: A cateterização do pâncreas durante a CPRE constituiu um fator preditivo para o desenvolvimento de pancreatite aguda pós-CPRE.
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Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida M, Mayumi T, Strasberg S, Pitt HA, Gadacz TR, Büchler MW, Belghiti J, de Santibanes E, Gouma DJ, Neuhaus H, Dervenis C, Fan ST, Chen MF, Ker CG, Bornman PC, Hilvano SC, Kim SW, Liau KH, Kim MH. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. ACTA ACUST UNITED AC 2007; 14:52-8. [PMID: 17252297 PMCID: PMC2784515 DOI: 10.1007/s00534-006-1156-7] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 08/06/2006] [Indexed: 12/11/2022]
Abstract
Because acute cholangitis sometimes rapidly progresses to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt diagnosis and severity assessment are necessary for appropriate management, including intensive care with organ support and urgent biliary drainage in addition to medical treatment. However, because there have been no standard criteria for the diagnosis and severity assessment of acute cholangitis, practical clinical guidelines have never been established. The aim of this part of the Tokyo Guidelines is to propose new criteria for the diagnosis and severity assessment of acute cholangitis based on a systematic review of the literature and the consensus of experts reached at the International Consensus Meeting held in Tokyo 2006. Acute cholangitis can be diagnosed if the clinical manifestations of Charcot's triad, i.e., fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice are present. When not all of the components of the triad are present, then a definite diagnosis can be made if laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction are obtained. The severity of acute cholangitis can be classified into three grades, mild (grade I), moderate (grade II), and severe (grade III), on the basis of two clinical factors, the onset of organ dysfunction and the response to the initial medical treatment. "Severe (grade III)" acute cholangitis is defined as acute cholangitis accompanied by at least one new-onset organ dysfunction. "Moderate (grade II)" acute cholangitis is defined as acute cholangitis that is unaccompanied by organ dysfunction, but that does not respond to the initial medical treatment, with the clinical manifestations and/or laboratory data not improved. "Mild (grade I)" acute cholangitis is defined as acute cholangitis that responds to the initial medical treatment, with the clinical findings improved.
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Affiliation(s)
- Keita Wada
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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Abstract
OBJECTIVE Medical treatment is the first-line management in patients with acute cholangitis but those who fail to respond to antibiotic treatment need urgent biliary decompression. Early prediction of patients with acute cholangitis who require urgent biliary drainage is important because this group of patients has a higher morbidity and mortality from this pathology. This study was undertaken to identify early predictors for emergency biliary decompression in patients with acute cholangitis. METHODS This is a retrospective analysis of a prospective database of 171 consecutive patients with acute cholangitis managed in a regional hospital in Hong Kong. Emergency biliary drainage was performed when conservative treatment failed. Twenty-four variables that could be assessed upon admission were analyzed for the prediction of the need for emergency biliary decompression. RESULTS Thirty-one (18.1%) patients needed emergency biliary drainage. Older age (P=0.001), habit of chronic smoking (P=0.04), prolonged prothrombin time (P=0.025), higher blood glucose level (P=0.002), and dilated common bile duct diameter on ultrasonography (P=0.047) predicted the need for urgent biliary drainage. Patients aged older than 75 years had a significantly higher chance of failure of conservative treatment than those aged 75 years or less (26.5% versus 10.2%, P=0.005). CONCLUSIONS Biliary drainage should be considered early in cholangitic patients aged older than 75 years and/or chronic smoking because they are less likely to respond to conservative treatment. Further studies are required to confirm that the outcome of patients with acute cholangitis can be improved by this selective approach.
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Affiliation(s)
- Yeung Yuk Pang
- Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong.
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Englesbe MJ, Dawes LG. Resistant pathogens in biliary obstruction: importance of cultures to guide antibiotic therapy. HPB (Oxford) 2005; 7:144-8. [PMID: 18333179 PMCID: PMC2023940 DOI: 10.1080/13651820510028792] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis, infection of the bile ducts, is a serious condition that necessitates prompt and efficacious treatment for a good clinical outcome. A single center retrospective study of cholangitis was conducted to better define the spectrum of responsible pathogens and their antibiotic sensitivities. METHODS We studied all patients at our hospital who had cholangitis from January 1998 to June 2004. Patients were identified by ICD-9 codes and the cause of the cholangitis, the treatment and culture data were noted by review of the medical record. RESULTS Thirty patients presented with cholangitis as noted by the clinical symptoms of jaundice, fever and abdominal pain. The cause of the biliary obstruction was gallstones in 18 patients, benign biliary strictures in 5 and malignant obstruction in 7. All the patients with malignant obstruction with cholangitis had stents; there were no cases of cholangitis in malignant obstruction unless prior instrumentation had been performed. The most common isolates were Enterococcus>E. coli>Enterobacter>Klebsiella. Sixty-four percent of blood cultures and all but one of the bile cultures grew organisms. Seventy-two percent of patients had positive blood cultures with at least one resistant organism present and 36% had organisms resistant to multiple antibiotics. Fifty percent of patients with benign biliary disease and positive blood cultures had multiple organisms growing in their blood. Three-quarters of the isolates were resistant to one or more antibiotics and one-quarter of isolates were resistant to three or more antibiotics. Resistant organisms were found regardless of the cause of the biliary obstruction. DISCUSSION For all causes of cholangitis, there is a high incidence of positive blood cultures and a high rate of antibiotic resistance. For optimal treatment, blood and/or bile cultures should be routinely performed to optimize antibiotic therapy.
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Hui CK, Liu CL, Lai KC, Chan SC, Hu WHC, Wong WM, Cheung WW, Ng M, Yuen MF, Chan AO, Lo CM, Fan ST, Wong BCY. Outcome of emergency ERCP for acute cholangitis in patients 90 years of age and older. Aliment Pharmacol Ther 2004; 19:1153-8. [PMID: 15153168 DOI: 10.1111/j.1365-2036.2004.01962.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND An increasing proportion of the general population across the Western World now survives to an advanced age. However, there is limited data on the outcome of therapeutic endoscopic retrograde cholangiopancreatography in patients above 90 years of age with severe acute cholangitis. AIM To determine the relative frequency of postendoscopic retrograde cholangiopancreatography complication in this group of patients. METHODS The postendoscopic retrograde cholangiopancreatography complications related outcome of 64 patients aged 90 years and above (Group 1) with severe acute cholangitis were retrospectively compared with 165 patients under the age of 90 years (Group 2). RESULTS The postendoscopic retrograde cholangiopancreatography complication rate was 4.7% (three patients) in Group 1 and 7.3% (12 patients) in Group 2. There was no significant difference in the postendoscopic retrograde cholangiopancreatography complication rate between the two groups (P = 0.567). The relative frequency of 30-day mortality was 7.8% (five patients) in Group 1 and 4.2% (seven patients) in Group 2 (P = 0.227). CONCLUSION Urgent biliary decompression with endoscopic retrograde cholangiopancreatography in patients 90 years of age and older with severe acute cholangitis is a safe and effective procedure in the hands of highly skilled endoscopists and is not associated with increased morbidity or mortality even in this group of high risk patients.
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Affiliation(s)
- C-K Hui
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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