Acute Biliary Diseases Research Articles

Part 2: Current Concepts in Radiologic Imaging & Intervention in Acute Biliary Tract Diseases.

Acute cholangitis is encountered commonly in critically ill, often elderly, patients. The most common causes of cholangitis include choledocholithiasis, biliary strictures, and infection from previous endoscopic, percutaneous, or surgical intervention of the biliary tract. Rare causes of acute cholangitis in the United States include sclerosing cholangitis and recurrent pyogenic cholangitis, the latter predominantly occurring in immigrants of Asian descent. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, gastroenterologists, endoscopists, and infectious disease physicians typically involved in the care of these patients. In this paper intended for intensivists predominantly, we will review the imaging findings and radiologic interventional management of critically ill patients with acute cholangitis, primary and secondary sclerosing cholangitis, and recurrent pyogenic cholangitis.

WTP4.13 The Quality of Service of Index Admission Laparoscopic Cholecystectomy For Patients With Acute Biliary Symptoms: Re-audit From a Rural District General Hospital

Abstract Aims To continue evaluating our service of index admission laparoscopic cholecystectomy for acute biliary diseases. Methods A retrospective analysis was conducted. All patients who had an index admission laparoscopic cholecystectomy between 2016 & 2021 were identified from the hospital database. Data including demographics, time to diagnostic imaging, surgical technique, complications, re-operation, re-admission and mortality were collected from the hospital clinical information system “Myrddin” and patients’ notes. Results There were 335 patients (male: female 128:207) with median age of 62 years (range 16- 92years) presented as emergency with acute biliary symptoms and had index admission cholecystectomy. The reasons for acute admission were acute cholecystitis (n=205) acute pancreatitis (n=60), biliary colic (n=43) and calcular obstructive jaundice (n=27). The time to diagnostic imaging ranges from same day of admission to 3 days (mean= 0.81 days). Laparoscopic cholecystectomy was done in 333/335 with conversion rate of 1.5% (n=5). Five patients (1.5%) required re-operation because of bile leak. There was no major bile duct injury, no bleeding requiring any intervention. The re-admission rates within one week and within 30 days of surgery were (2.4%) and (0.9%) consecutively. Mean length of in-hospital stay (LOS) was calculated only for patients with acute cholecystitis and biliary colic (n=248) and it was 6.8 days. Mortality over 9 years period was 0.579% (3/518).These results are comparable to the available data from the national and international published data. Conclusions Index admission laparoscopic cholecystectomy is still safe and meets the recommended quality standards. Time to surgery has reduced compared to previous cycle and this led to decrease in LOS.

Acute cholecystitis: diagnosis, complications and therapy: an integrative literature review

Acute cholecystitis is an inflammatory pathological process of the gallbladder resulting from acute obstruction of the cystic duct. Although it is more frequent in females, the number of male patients increases with advancing age, reaching 30% of cases over 65 years of age. It presents as a surgical emergency and usually requires hospitalization for treatment. It is associated with significant morbidity and mortality, especially in elderly patients. The most frequent cause is lithiasis, responsible for 90% of cases. In the differential diagnosis of acute cholecystitis, inflammatory or non-inflammatory diseases with expression located in the upper right hemiabdomen must be considered. They are: right-based pneumonia, hepatitis, pyelonephritis, and even myocardial ischemia or infarction. Other diseases of the digestive tract should be kept in mind, such as acute appendicitis of subhepatic location, complicated peptic ulcer and acute pancreatitis. Imaging of the gallbladder and bile ducts has changed dramatically in the last 20 years. The replacement of transparietal cholangiography and oral cholecystography by modern, non-invasive techniques has brought great advances in the diagnosis of diseases of the bile ducts. Currently, the diagnosis and imaging follow-up of biliary diseases is based on ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy. US remains the test of choice in the initial evaluation of acute biliary diseases, due to its ease of performance, wide availability and high accuracy in the diagnosis of acute cholecystitis.

Enzyme pattern of biliary colic: A counterintuitive picture.

AIMTo evaluate the diagnostic value of serial biochemical blood tests in the diagnosis of biliary colic.METHODSFiles were reviewed of 1039 patients who were admitted to the Share’e Zedek Medical Center emergency department between the years 2012-2013, and received the coding of acute biliary disease. Of these, the first 100 cases were selected that met the following criteria: (1) a diagnosis of biliary colic or symptomatic cholelithiasis; (2) at least two biochemical blood tests performed; and (3) 18 years of age or older. Patients with other acute biliary diseases were excluded. The biochemical profile of the patients was analyzed as were their clinical and radiological findings.RESULTSThree-quarters of the patients were women, whose average age of 37 years was younger than the average of the men, at 50 years. According to their histories, 47% of the patients had previously known cholelithiasis. Pain in either the right upper quadrant or the epigastrium was the presenting symptom in 93% cases. The greatest change in serum biochemical results was seen during the first day of the patients’ admissions. Alanine aminotransferase (ALT) showed the highest initial rise above the reference range, followed by aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), bilirubin and alkaline phosphatase (ALKP) - all these increases were statistically significant (P < 0.05). AST showed the sharpest decline followed by bilirubin and ALT. GGT and ALKP did not fall. A sharp rise and fall in liver enzymes, especially during the first day, most prominently in AST and ALT, was seen in 70% percent of cases. In 65% of cases trans-abdominal sonography did not give diagnostic findings.CONCLUSIONSerial serum liver enzyme measurements are helpful in the initial diagnosis of acute biliary colic.

Advanced laparoscopic fellowship training decreases conversion rates during laparoscopic cholecystectomy for acute biliary diseases: A retrospective cohort study

Introduction: Acute biliary pathology is a risk factor for conversion to open surgery and increased surgical morbidity during laparoscopic cholecystectomy (LC). The purpose of our study was to examine the impact of an advanced laparoscopic fellowship-trained surgeon on risks of conversion, surgical morbidity, and postoperative complications in this patient population. Methods: Of 1382 patients who underwent an LC from January 2008 to August 2011, 592 patients were diagnosed with an acute biliary process and were included in the study. Patients were divided into two groups; those operated on by an advanced laparoscopic fellowship-trained surgeon (N = 237), and those operated on by a non-laparoscopic fellowship-trained surgeon (N = 355). The primary end-points were conversion rates and surgical morbidity. The secondary end-point was operative time. Results: Fellowship-trained surgeons were more likely to perform IOC (57%) versus non-fellowship trained surgeons (20%) (p < 0.0001). The conversion rate for the fellowship-trained group was significantly lower than for the non-fellowship trained group (1.7% vs 8.5%, p = 0.0004). The intraoperative and postoperative complication rates for the fellowship-trained group were not significantly different. The operative time was slightly longer in the non-fellowship trained group compared to the fellowship-trained group (104 min vs 111 min, p = 0.04). Discussion: Our data demonstrate that advanced laparoscopic fellowship training decreases conversion rates of laparoscopic cholecystectomy for acute biliary pathology. Moreover, given the lower conversion rates, patients may have experienced shorter hospitalizations. Conclusions: Formal advanced laparoscopic fellowship training may decrease length of stay among patients presenting with acute biliary pathology who undergo laparoscopic cholecystectomy.

Multidetector CT of Emergent Biliary Pathologic Conditions

Various biliary pathologic conditions can lead to acute abdominal pain. Specific diagnosis is not always possible clinically because many biliary diseases have overlapping signs and symptoms. Imaging can help narrow the differential diagnosis and lead to a specific diagnosis. Although ultrasonography (US) is the most useful imaging modality for initial evaluation of the biliary system, multidetector computed tomography (CT) is helpful when US findings are equivocal or when biliary disease is suspected. Diagnostic accuracy can be increased by optimizing the CT protocol and using multiplanar reformations to localize biliary obstruction. CT can be used to diagnose and stage acute cholecystitis, including complications such as emphysematous, gangrenous, and hemorrhagic cholecystitis; gallbladder perforation; gallstone pancreatitis; gallstone ileus; and Mirizzi syndrome. CT also can be used to evaluate acute biliary diseases such as biliary stone disease, benign and malignant biliary obstruction, acute cholangitis, pyogenic hepatic abscess, hemobilia, and biliary necrosis and iatrogenic complications such as biliary leaks and malfunctioning biliary drains and stents. Treatment includes radiologic, endoscopic, or surgical intervention. Familiarity with CT imaging appearances of emergent biliary pathologic conditions is important for prompt diagnosis and appropriate clinical referral and treatment.

Decreasing Mortality From Acute Biliary Diseases That Require Endoscopic Retrograde Cholangiopancreatography: A Nationwide Cohort Study

The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality. We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs. From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality. In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.

Magnetic Resonance Cholangiopancreatography in the Diagnosis of Haemobilia

Haemobilia is a rare cause of unrecognized gastrointestinal bleeding and is hard to diagnose. Through the present case report we aim to corroborate magnetic resonance relevance in the evaluation of biliary system and bile features, investigating on its role in patients with acute biliary diseases. We report a case of a Caucasian 48-year-old man who was admitted due to abdominal pain and fever. After an ultrasonography exam we detected multiple cysts in the hepatic left lobe: imaging features, laboratory findings, and patient past work experience (woodcutter) suggested a diagnosis of hepatic Echinococcosis. Once surgery decision was taken, patient underwent an intervention of cystopericystectomy. On the 8th postoperative day, the procedure was complicated by black stool, jaundice, and severe anaemia. Acomputed tomography revealed an inhomogeneous collection with some air bubbles in the area of previous surgical intervention, but it was not able to solve the diagnosis question. At this stage a magnetic resonance study was mandatory. On T2-weighted images we observed an expanse gallbladder with hypointense intraluminal material and a considerable intrahepatic biliary system dilatation due to bloody material. On the basis of these examination results, we supposed haemobilia arising from previous surgical intervention. A therapeutic endoscopic retrograde cholangiopancreatography procedure led to decompression of biliary system through a major papilla sphincterotomy with spillage of bile mixed with blood clots.

The rising tide of cholecystectomy for biliary dyskinesia

Expert consensus defines biliary dyskinesia as a rare disorder of the gall-bladder characterised by pain and impaired gall-bladder function. To determine trends in cholecystectomy rates for biliary dyskinesia in the United States. As biliary dyskinesia does not have a distinct diagnosis code, the narrative diagnoses for patients were reviewed and abstracted for 200 patients treated for the most commonly used diagnosis codes for biliary dyskinesia (validation sample). Time trends in cholecystectomies and hospitalisations for biliary diseases were assessed using the Nationwide Inpatient Sample (Agency for Healthcare Research and Quality) based on codes for cholecystectomy and diagnosis codes for different biliary disorders. In the validation sample, biliary dyskinesia accounted for 81% of the patients with ICD-9 code 575.8 (gall-bladder disease not elsewhere specified). Between 1997 and 2010, admissions for acute cholecystitis and complications of gallstone disease decreased slightly, whereas admissions with the primary diagnosis code ICD-9 575.8 tripled. This rise was most pronounced in the paediatric population (700% increase), with biliary dyskinesia accounting for more than 10% of cholecystectomies. Compared with acute biliary diseases, significantly more of the elective hospitalisations were covered by private insurances. Practice patterns differ from expert opinion, with biliary dyskinesia accounting for an increasing fraction of cholecystectomies. The rise in these elective interventions is associated with a shift to a younger, low risk and predominantly privately insured population. Considering the benign nature of biliary dyskinesia, it is time to reassess the need for operative interventions, which have never been compared with active conservative therapy.

Association between hospital volume and outcomes of elderly and non‐elderly patients with acute biliary diseases: A national administrative database analysis

This study aimed to investigate the relationship between hospital volume and clinical outcomes of elderly and non-elderly patients with acute biliary diseases using data from a national administrative database. Overall, 26720 elderly and 33774 non-elderly patients with acute biliary diseases were referred to 820 hospitals in Japan. Hospital volume was categorized into three groups based on the case numbers during the study period: low-volume, medium-volume and high-volume. We compared the risk-adjusted length of stay (LOS) and in-hospital mortality in relation to hospital volume. These analyses were stratified according to the presence of invasive treatments for acute biliary diseases. Multiple linear regression analyses showed that increased hospital volume was significantly associated with shorter LOS in both elderly and non-elderly patients with and without invasive treatments. Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in elderly patients. The odds ratio for high-volume hospitals was 0.672 in elderly patients without invasive treatments (95% confidence interval [CI] 0.533-0.847, P=0.001) and 0.715 in those with invasive treatments (95% C, 0.566-0.904, P=0.005). However, no significant differences for in-hospital mortality were seen in non-elderly patients with and without invasive treatments. This study has highlighted that higher volume hospitals significantly reduced LOS and in-hospital mortality for elderly patients with acute biliary diseases, but not non-elderly patients. The current results are of value for elderly healthcare policy decision-making, and highlight the need for further studies into the quality of care for elderly patients.

Massive intraperitoneal bleeding due to hemorrhagic cholecystitis and gallbladder rupture: CT findings

Hemorrhagic cholecystitis with subsequent gallbladder rupture and torrential bleeding is a very rare but life-threatening complication of acute biliary tract diseases. Its clinical presentation may be dubious and therefore Computed Tomography (CT) imaging plays a crucial role in a prompt and accurate diagnosis. We present a case of a 64 year-old male who was admitted to the emergency department with clinical findings of acute cholecystitis. During the following hours the patient became hemodynamically unstable and an emergency abdominal CT scan was performed. CT revealed massive hemoperitoneum containing free gallstones. In addition, active extravasation of iv contrast material inside the gallbladder lumen was demonstrated. Based on these findings hemorrhagic cholecystitis with gallbladder rupture was suspected and the patient underwent urgent laparotomy. We describe specific CT findings of this rare condition, thus emphasizing the role of imaging in facilitating urgent surgical treatment.

Rationelle Diagnostik des „akuten Abdomens“

In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.

Relation of pathoanatomic substrate and incidence of bacterial infection in the acute biliary pathology

Acute biliary diseases have become the most common indication for major abdominal surgery. We investigated 60 patients who underwent surgery for the acute biliary diseases, within 48 hours from the onset of the illness (group I), and over longer preoperative interval (48 h up to 5 days) (group II). Surgical specimen (gallbladder) was histologically examined. Samples for microbiological exams were obtained from gallbladder, common bile duct, Lund's node, gallbladder bed and peritoneal cavity. Positive bile cultures were found in 43% of group I, and in 70% of group II (p<0.05). Microbiological analysis revealed 13 different species, mostly Gram negative aerobic rods (69%). The incidence of bacteriobilia was in correlation with HP of lesions (79% in the acute and 18% in chronic lesions; p<0.01), what testified the importance of time interval and role of bacterial factor in the acute biliary pathology. Septic complications strictly occurred in patients with positive biliary findings. Early surgical treatment eliminates focus, and stops further development of intraabdominal and systemic septic complications. Correlation between bacteriobilia and septic sequelae calls for prophylactic use of antibiotics.

Clinical Studies of Acute Biliary Duct Diseases

Clinical Studies of Acute Biliary Duct Diseases

Express diagnostics of acute liver and biliary tract diseases with jaundice syndrome in emergency surgery

The relevance of the diagnosis and differentiation of acute liver and biliary tract diseases with other diseases accompanied by jaundice is beyond doubt. This problem is of particular importance in the practice of emergency abdominal surgery when patients with jaundice are admitted to a hospital providing urgent care. The difficulty of establishing the type of jaundice and their prognosis is well known. It is due to both the severity of the patients' condition and the presence of contraindications to complex diagnostic studies.

Influence of age on the clinical presentation of acute biliary tract disease.

The influence of age on the presenting manifestation of acute biliary tract disease was evaluated by retrospective review of all cases in which this diagnosis was confirmed at operation over a 30-month period. Results indicated that acute biliary tract diseases in elderly patients presents in a manner not statistically significantly different from younger patients (p greater than 0.05 for all parameters studied). Although such disorders in the elderly occasionally present in an unusual fashion, the majority of older patients present with abnormalities such as pain, jaundice, fever, and leukocytosis as commonly or even more frequently than younger patients.