Endoscopic Management of Recurrent Pyogenic Cholangitis: A Single Center Retrospective Review

Abstract

Background: Recurrent pyogenic cholangitis (RPC) can be treated by endoscopic stone removal. Methods: A retrospective review was performed using endoscopic and medical records of all adult patients with recurrent pyogenic cholangitis who underwent endoscopic retrograde cholangiopancreatograms (ERCP) between 1999-2003 at a tertiary medical center. Medical records of all patients were reviewed including basic demographics, initial presenting symptoms, surgeries of the biliary tract, and all endoscopic retrograde cholangiopancreatograms (ERCP). 20 patients were identified. There was an equal male to female distribution and the age range was 37-83 years with an average age of 52. Results: Of the 20 patients, 14 (70%) were of the Asian-Pacific Islander ethnicity. Initial presenting symptoms included: jaundice in 8/20 (40%), abdominal pain 15/20 (75%), fever 5/20 (25%). 7/20 (35%) had abnormal liver function tests (LFTs) on initial presentation. The cholangiogram findings were as follows: 19/20 (95%) had bilateral biliary tract disease, 7/20 (35%) had a selectively dilated left system over the right. 10/20 (50%) were found to have strictures. A total of 212 ERCPs were performed over the course of four years with a mean follow-up of 11 months (range from 1-48 months). 5/20 (25%) had undergone a choledochoduodenostomy (3/5 prior to 1999), 2/20 (10%) had undergone a hepaticojejunostomy (1/2 prior to 1999 and 1/2 due to the inability to endoscopically remove all stones). All patients underwent an endoscopic biliary sphincterotomy. 14/20 (70%) underwent routine/surveillance endoscopic therapy (after the initial ERCP) for removal of stones. Only 4/20 (20%) were on a daily ursodeoxycholic acid during the review period. Surveillance ERCPs were performed every 2-6 months dependent on the patient's cholangiogram findings and symptoms. Bile duct stones were present in 70% of the surveillance ERCPs. The average number of acute cholangitis attacks decreased from an average of 3-5 episodes/year prior to surveillance ERCPs to 1-2 episodes/year during the surveillance period. There were no complications noted from the ERCPs. Conclusions: Stones were present even when symptoms were absent . The procedure was safe. Endoscopic routine surveillance and management proved to be an effective way to manage this disease and the presence of previous surgical intervention did not eliminate the need for endoscopic intervention.