Cholangitis Research Articles

Endoscopic Retrograde Cholangiopancreatography during Pregnancy

Physiological changes caused by pregnancy promote the formation of gallstones, increasing the risk of acute cholecystitis, cholangitis, and cholelithiasis that occur during pregnancy. Since these diseases can be fatal to both mother and fetus, active treatment is critical. Biliary gallstones are preferably treated using endoscopic retrograde cholangiopancreatography (ERCP), even during pregnancy. While there is no alternative, safer and easier treatment method, complications from ERCP are lethal; therefore, several risks and benefits must be considered. First, various tests should be conducted and considered to determine whether ERCP is necessary. The risk of congenital disabilities from radiation exposure to the fetus during ERCP should be considered and minimized. Furthermore, clinicians should be aware of and use safe anesthetic agents and antibiotics that are safe to use during pregnancy. Finally, ERCPists should be familiar with various technical methods, such as the recently introduced ERCP technique without radiation exposure, stent drainage without complete removal of gallstones in the case of large biliary stones, and removal of biliary stones after childbirth. Pregnancy is not a contraindication for ERCP; as a lifesaving procedure, it should be performed when necessary. Even though the safety of ERCP is considered an acceptable risk in pregnancy, clinicians should continue to try and find safer ways for pregnant women and fetuses being treated for cholelithiasis.

Predictive value of presepsin and acylcarnitines for severity and biliary drainage in acute cholangitis.

Bacteremia, which is a major cause of mortality in patients with acute cholangitis, induces hyperactive immune response and mitochondrial dysfunction. Presepsin is responsible for pathogen recognition by innate immunity. Acylcarnitines are established mitochondrial biomarkers. To clarify the early predictive value of presepsin and acylcarnitines as biomarkers of severity of acute cholangitis and the need for biliary drainage. Of 280 patients with acute cholangitis were included and the severity was stratified according to the Tokyo Guidelines 2018. Blood presepsin and plasma acylcarnitines were tested at enrollment by chemiluminescent enzyme immunoassay and ultra-high-performance liquid chromatography-mass spectrometry, respectively. The concentrations of presepsin, procalcitonin, short- and medium-chain acylcarnitines increased, while long-chain acylcarnitines decreased with the severity of acute cholangitis. The areas under the receiver operating characteristic curves (AUC) of presepsin for diagnosing moderate/severe and severe cholangitis (0.823 and 0.801, respectively) were greater than those of conventional markers. The combination of presepsin, direct bilirubin, alanine aminotransferase, temperature, and butyryl-L-carnitine showed good predictive ability for biliary drainage (AUC: 0.723). Presepsin, procalcitonin, acetyl-L-carnitine, hydroxydodecenoyl-L-carnitine, and temperature were independent predictors of bloodstream infection. After adjusting for severity classification, acetyl-L-carnitine was the only acylcarnitine independently associated with 28-d mortality (hazard ratio 14.396; P < 0.001) (AUC: 0.880). Presepsin concentration showed positive correlation with direct bilirubin or acetyl-L-carnitine. Presepsin could serve as a specific biomarker to predict the severity of acute cholangitis and need for biliary drainage. Acetyl-L-carnitine is a potential prognostic factor for patients with acute cholangitis. Innate immune response was associated with mitochondrial metabolic dysfunction in acute cholangitis.

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones. We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105years, mean 79.1years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram. The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success. PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate. • PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Feasibility of Biliary Drainage Using a Novel Integrated Biliary Stent and Nasobiliary Drainage Catheter System for Acute Cholangitis.

Background Acute cholangitis is caused by cholestasis and bacterial infection, and if exacerbated, sepsis may occur and be fatal. Biliary drainage is recommended for acute cholangitis regardless of severity, except in some cases of mild acute cholangitis, in which antibiotics are effective. A novel integrated device comprising a biliary drainage stent and a nasobiliary drainage tube, called the UMIDAS NB stent (UMIDAS Inc., Kanagawa, Japan), was developed. In this study, we evaluated the efficacy and safety of biliary drainage using the UMIDAS NB stent outside type for acute cholangitis in clinical practice. Methods Patients with acute cholangitis with common bile duct stones or distal biliary strictures who underwent biliary drainage with the UMIDAS NB stent outside type at our institution between January 2022 and December 2022were examined retrospectively. The UMIDAS NB stent outside type was placed transpapillary using endoscopic retrograde cholangiopancreatography (ERCP). Patients with biliary drainage stent placement other than the UMIDAS NB stent outside type on the same ERCP session and patients with acute cholecystitis were excluded. Results A total of 13 patients were included in this study. The severity of cholangitis was mild in four cases, moderate in five, and severe in four. There were eight cases of common bile duct stones and five cases of pancreatic cancer. The stent diameter was 7 French scale (Fr) in five cases and 8.5 Fr in eight cases. The median procedure time was 20 minutes. Clinical success was achieved in all 13 patients (100%). No treatment-related adverse events were observed. Unintended removal of the nasobiliary drainage tube was not observed. There were no cases of biliary drainage stent dislocation with nasobiliary drainage tube removal. Conclusions Although the sample size was small, our studydemonstrated that biliary drainage with the UMIDAS NB stent outside type was effective and safe for patients with acute cholangitis who had common bile duct stones or distal biliary strictures, regardless of the severity of cholangitis.

The efficacy of a novel integrated outside biliary stent and nasobiliary drainage catheter system for acute cholangitis: a single center pilot study.

Endoscopic biliary drainage is the gold standard treatment for cholangitis. The two methods of biliary drainage are endoscopic biliary stenting and nasobiliary drainage. A novel integrated outside biliary stent and nasobiliary drainage catheter system (UMIDAS NB stent; Olympus Medical Systems) was recently developed. In this study, we evaluated the efficacy of this stent in the treatment of cholangitis caused by common bile duct stones or distal bile duct strictures. We conducted a retrospective pilot study by examining the medical records of patients who required endoscopic biliary drainage for cholangitis due to common bile duct stones or distal bile duct strictures, and who were treated with a UMIDAS NB stent, between December 2021 and July 2022. Records of 54 consecutive patients were reviewed. Technical and clinical success rates were 47/54 (87.0%) and 52/54 (96.3%), respectively. Adverse events were observed in 12 patients, with six patients experiencing pancreatitis as an adverse event, following endoscopic retrograde cholangiopancreatography (ERCP). Regarding late adverse events, five cases of biliary stent migration into the bile duct were observed. Disease-related death occurred in one patient. The outside-type UMIDAS NB stent is an efficacious new method for biliary drainage and can be applied to many indications.

Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study.

Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.

Factors associated with clinical outcome in geriatric acute cholangitis patients.

We aimed to determine the risk factors associated with the clinical outcome in cases of acute cholangitis among the geriatric age group. Patients aged >65 years hospitalized with the diagnosis of acute cholangitis in an emergency internal medicine clinic were included in this study. The study population comprised 300 patients. In the oldest-old group, the rates of severe acute cholangitis and intensive care unit hospitalization (39.1% vs. 23.2%, p<0.001) were higher. The mortality rate was also higher in the oldest-old group (10.4% vs. 5.9%, p=0.045). The presence of malignancy, ICU hospitalization, decreased platelet levels, decreased hemoglobin levels, and decreased albumin levels were associated with mortality. In the multivariable regression model in which variables associated with Tokyo severity were included, the associated factors for membership in the severe risk group compared to the moderate risk group were decreased platelet count (OR: 0.96; p=0.040) and decreased albumin level (OR: 0.93; p=0.027). Increasing age (OR: 1.07; p=0.001), malignancy etiology (OR: 5.03; p<0.001), increasing Tokyo severity (OR: 7.61; p<0.001), and decreasing lymphocyte count (OR: 0.49; p=0.032) were determined to be associated with ICU admission. Decreasing albumin levels (OR: 0.86; p=0.021) and ICU admission (OR: 16.43; p=0.008) were determined to be factors associated with mortality. Worse clinical outcomes occur among geriatric patients with increasing age.

Spontaneous biloma manifesting with massive upper gastrointestinal bleed: case report

Spontaneous biloma is a rare non-traumatic lesion in whi­ch the extrahepatic or intrahepatic bile duct perforates spontaneously with no discernable cause. We present a case of spontaneous biloma in a 68 years old male patient with cholelithiasis and concurrent choledocholithiasis, who presented with acute severe cholangitis. There was no history of abdominal surgery, instrumentation, or trauma in the past. Initial ultrasonography (USG) abdomen showed central intrahepatic dilation, cholelithiasis, and choledocholithiasis. A sizeable hypoechoic lesion with few internal septations was present adjacent to the left lobe of the liver, with USG suspicion of a hydatid cyst. The lesion was abutting and displacing the stomach anteromedially. The patient had an acute renal failure with hemodynamic instability at presentation. The patient was managed with emergency endoscopic drainage under ultrasound guidance and improved after that. On the fourth day, after endoscopic drainage, the patient had a massive upper gastrointestinal (UGI) bleed due to erosion and pressure necrosis of the gastric wall due to biloma. The patient was managed successfully with sleeve gastrectomy and de-roofing of the cyst.

Improving Empiric Antibiotic Therapy Among Cancer Patients With Acute Cholangitis

Abstract Introduction Acute cholangitis (AC) is a hepatobiliary infection that requires prompt antibiotic therapy. Providers have to rely on empiric antibiotic guidelines, before receiving culture results. These antibiotic guidelines require routine surveillance of the biliary microbial flora and resistance patterns found in cultures to increase accuracy and appropriateness of empiric therapy. This is particularly essential in cancer patients who are more likely to be exposed to various antibiotics, potentially creating unique bactobilia, and fungobilia selection pressures that are different from the general patient population and require empiric therapy to halt AC progression to septicemia, shock, or mortality. This unique population is poorly researched and primary literature is relatively scarce. Methodology A retrospective chart review was performed to identify all patients between the age of 18 and 85 years who met the criteria for positive biliary culture and were treated for AC using empiric antibiotic treatment at the H. Lee Moffitt Cancer Center and Research Institute from January 2012 to January 2019. The patient information and laboratory results were analyzed to identify the microbial spectrum and drug resistance in bile cultures of cancer patients. Aim The aim of the study is to review the microbial patterns and characteristics of AC in immunocompromised patients with cancer. Results Pancreatic carcinomas and cholangiocarcinoma were most prevalent malignancies among patients. Although most bile cultures were polymicrobial, further analysis indicated Enterococcus species. Streptococcus species, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida albicans were the most common isolates. Conclusions Cholangitis in cancer patients develops because of cholestasis from cancer obstructing the biliary flow mostly because of pancreatic cancer, cholangiocarcinoma, and metastatic cancer to the porta hepatis. Empiric antibiotic therapy should include broad-spectrum coverage for usual enteric flora.

Endogenous Endophthalmitis From a Klebsiella pneumoniae Liver Abscess: The Incidence, Risk Factors, and Utility of Imaging

We investigated the rate of ophthalmologic examinations to detect endogenous endophthalmitis in patients with pyogenic liver abscesses (PLAs) and the incidence and risk factors of endophthalmitis from a PLA caused by Klebsiella pneumoniae (PLA-K). A retrospective case series METHODS: A total of 536 patients admitted to a university hospital in Korea, to treat PLAs during 2012-2022 were primarily included. The proportion of patients who were referred for ophthalmologic examinations was investigated and the incidence of endophthalmitis in 248 patients with PLA-K was calculated. Univariate and multivariate logistic regression analyses were performed to define risk factors including demographic characteristics, underlying diseases, radiological findings, and systemic conditions. A comprehensive ophthalmologic examination was performed in 73.7% of all patients with PLAs, and the incidence of endophthalmitis from a PLA-K was 7.3%. A liver abscess larger than 5 cm in size increased the incidence of endogenous endophthalmitis 4-fold compared to smaller abscesses (OR=4.01, 95% CI=1.02 - 15.78, P=.047), and portal or hepatic vein thrombophlebitis increased the incidence approximately 4-fold (OR=4.04, 95% CI=1.10 - 14.83, P=.036). Acute cholangitis was approximately 8-fold (OR=8.33, 95% CI=1.25 - 55.71, P=.029), and disseminated intravascular coagulation (DIC) was approximately 6-fold (OR=5.76, 95% CI=1.22 - 27.21, P=.027) more related to prevalence of endophthalmitis. Other extrahepatic infections increased the incidence approximately 43-fold (OR=43.06, 95% CI=10.14 - 182.90, P < .001). . Clinicians should consider the risk of endogenous endophthalmitis when PLA-K patients have large liver abscesses (> 5 cm), acute cholangitis, portal or hepatic vein thrombophlebitis, DIC, or other extrahepatic infections.

Characteristics and clinical outcomes of acute cholangitis in older patients.

Few studies are available on older patients with acute cholangitis. In this study, we aimed to examine the clinical characteristics of older patients with acute cholangitis. Patients aged 65years and over who were diagnosed with acute cholangitis between February 2019 and August 2022 were analyzed retrospectively. Patients eligible for the study were divided into two groups as those aged ≥ 80years (octogenarian) and those aged 65-79years (non-octogenarian). These two groups were then compared for many clinical characteristics. In addition, factors associated with in-hospital mortality were identified. Finally, a subgroup analysis was performed in patients with non-malignant etiology. Of a total of 309 enrolled patients, 120 (38.8%) were in the octogenarian group and 189 (61.2%) were in the non-octogenarian group. The mean age was 77.2 ± 8.0years and 51.8% were women. Severe disease and intensive care unit admission rates were higher in the octogenarian group (p = 0.035 and p = 0.002, respectively), but there was no significant difference in the rate of in-hospital mortality (p = 0.146). Malignant etiology (OR 2.990, 95% CI 1.131-7.904) and hypoalbuminemia (OR 0.824, 95% CI 0.751-0.903) were independent risk factors for in-hospital mortality. In the subgroup analysis of non-malignant etiology, the octogenarian group had a significantly higher in-hospital mortality rate than the non-octogenarian group (8.8% vs. 3.2%, p = 0.048). Among older patients with acute cholangitis, clinicians should closely monitor those aged 80years and over, as well as those with malignant etiology and hypoalbuminemia, due to their high risk of serious clinical events.

Limitations and Success Ratio of ERCP in the Treatment of Obstructive Jaundice

Background: Obstructive jaundice can be instigated by benign or malignant lesions. These problems are treated with biliary decompression, which can be done either endoscopically or surgically. Aim: The aim of the study is to assess the advantages and limitations as well as the therapeutic and diagnostic benefits of ERCP in the treatment of obstructive jaundice. Methods: This cross-sectional study was held in the Departments of General Surgery, Liaquat University of Medical and Health Science, Jamshoro for one-year duration from January 2022 to December 2022. A total of 70 consecutive patients were included with purposive sampling and with the diagnosis of obstructive jaundice done with ERCP. Patients with prior diagnostic or therapeutic endoscopic intervention or gastric outlet obstruction or prior gastric surgery were excluded from this study. The results are summarized in a table and conclusions are made. Results: The study included 70 patients (45 males and 25 females) with mean age of 45 years (21-70 years). The most common malignant causes of obstructive jaundice are papillary carcinoma (8.6%), cholangiocarcinoma (17.1%) and pancreatic Carcinoma (27.1%). The most common benign cause was bile duct stone (30%), followed by round warm biliary tree (5.8%) and papillary stenosis (11.4%). 30(93.8%) of patients done with stenting with 92% of success rate. Biopsies were performed to diagnose 8.6% of papillary tumors. 45.7% of patients done with stenting with 93.8% of success rate. In the remaining cases, the success rate was 100%. the most common reason for not performing ERCP; duodenal stenosis in 2.9%, abnormal papillary position in 4.3%, complete papillary obstruction in 4.3% and ampulla was not found endoscopically in 7.1% of subjects. Acute pancreatitis was the most communal complication occurred in 5.7% of cases. Bleeding occurs in 4.3% of cases; 4.3% have acute cholangitis and perforation in 2.9%. Conclusions: In spite of its complications and limitations, ERCP is a reliable stenting procedure as a palliative and tissue diagnostic tool for blockage due to malignant tumor and in the treatment of obstructive jaundice and most benign diseases. In this study, the effectiveness of ERCP in the treatment of obstructive jaundice is satisfactory. Keywords: Cholangiocarcinoma, pancreatic carcinoma, ERCP, Obstructive jaundice, and Stenting.

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135–15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359–5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138–5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184–5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598–9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090–6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286–5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912–7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138–0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143–0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990).Graphical abstract

Early is Not Superior to Late Endoscopic Intervention for Acute Cholangitis.

Acute cholangitis (AC) is a common emergency with a significant mortality risk. This study aimed to compare urgent, early, and late endoscopic retrograde cholangiopancreatography (ERCP) for AC. We retrospectively evaluated patients diagnosed with AC from June 2016 to May 2021. According to the time of ERCP, patients were divided into urgent (≤24h), early (24-48h), and late (≥48h) groups. Primary outcomes were technical success, in-hospital mortality, and 30-day mortality. Secondary outcomes were the length of hospital stay (LOS), ERCP-related adverse events, and 30-day readmission. We divided 121 patients who underwent ERCP into urgent (N = 15), early (N = 19), and late groups (N = 87). There was no in-hospital mortality and no significant difference in technical success (93.3% (urgent) vs 89.5% (early) vs 96.6% (late); P = .41) and 30-day mortality (P = .82). LOS in the urgent and early groups was shorter than that in the late group (13.93days vs 8.82days vs 14.20days, respectively; P = .02). There was no difference between groups for ERCP-related adverse events and 30-day readmission rates. Urgent or early ERCP was not superior to late ERCP for technical success and 30-day mortality. However, urgent or early ERCP was associated with shorter LOS than late ERCP.

Early Biliary Decompression Reduces Morbidity but Not Mortality in Acute Ascending Cholangitis.

Background Acute ascending cholangitis is a life-threatening infection due to biliary obstruction. Decompression via endoscopic retrograde cholangiography (ERC) or interventional radiologic (IR) drainage controls the source of the sepsis. Numerous studies have been published with conflicting data on whether earlier drainage affects morbidity and mortality. We sought to publish our experience at two Las Vegas community hospitals. Methods After IRB approval, over 4000 inpatient non-elective ERCs were analyzed between 2010 and 2019. Six-hundred and twenty-five patients met the 2018 Tokyo criteria for a "definitive diagnosis" of acute ascending cholangitis. A univariate and multivariate analysis was conducted to identify factors significantly associated with length of stay and mortality. Results On univariate analysis, patients who had drainage conducted within 24 hours had significantly shorter lengths of stay (p = 0.0012 95% CI [-88.1 to -21.8 hrs]), higher mean diastolic blood pressure (p=0.0029 95% CI [1.03 to 5.01 mm Hg]), and lower mean maximum temperature (p=0.0001 95% CI [-0.842 to -0.382oC]) when compared to patients who underwent decompression more than 24 hours after admission. There were no statistically significant differences in mortality between patients who underwent decompression within 24 hours of admission versus patients who underwent decompression beyond 24 hours of admission. On multivariate analysis, earlier decompression reduced the length of stay for patients with mild (p<0.0001), moderate (p<0.0001), and severe cholangitis (p=0.0023). Mortality was significantly associated with the worsening severity of the cholangitis (moderate [p=0.0001] and severe [p<0.0001], but not mild disease) and the use of vasopressors. Conclusions Timely biliary decompression within 24 hours of admission significantly reduces the length of stay, pyrexia, and hemodynamic abnormalities. In addition, our data corroborate the 2018 Tokyo guidelines that correlate the severity of cholangitis with mortality.

Bile duct penetrating duodenal wall sign: a novel computed tomography finding of common bile duct stone impaction into duodenal major papilla.

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. 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. A total of 40 patients (mean age 70.6years; 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). The BPDS was a unique CT imaging finding to identify common bile duct stone impaction regardless of stone attenuation with high accuracy.

A127 TIMING OF CHOLECYSTECTOMY AFTER ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A TERTIARY CENTRE: EVALUATION OF OUTCOMES

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for patients with choledocholithiasis. Early cholecystectomy (within 24 to 72 hours) is recommended after the initial ERCP to reduce the risk of subsequent biliary events. Purpose To investigate the timing of cholecystectomy after ERCP in patients with choledocholithiasis and its associated outcomes in a single tertiary care centre. Method This is a retrospective analysis of adult patients who underwent cholecystectomy after ERCP from August 2021 to April 2022 at the University of Alberta Hospital. Outcomes data were stratified according to the length of time between ERCP and cholecystectomy, within 72 hours (early) or after 72 hours (delayed). Result(s) During the study period, 55 subjects were examined. Indications for ERCP included gallstone pancreatitis (24/55, 44%), choledocholithiasis (19/55, 34%), and acute cholangitis (12/55, 21%). In total, 30 (55%) subjects received cholecystectomy within 72 hours, while 25 (45%) subjects received cholecystectomy after 72 hours. The two groups were comparable in age, sex ratios, and comorbidities. Out of the patients who received cholecystectomy after 72 hours, 8 (32%) subjects received their cholecystectomy on a subsequent admission. Of these, 2 subjects developed recurrent biliary events before their cholecystectomy, and 1 subject required a conversion to open cholecystectomy. There were no recurrent biliary events amongst the individuals with early cholecystectomy. Subjects who received early cholecystectomy had a shorter total hospital stay compared to those with delayed cholecystectomy (4.5 days vs 7.3 days, p=0.0002). There was no significant difference between early and late cholecystectomy in conversion rate (3% vs 8%, p=0.58), average operating time (86min vs 83min, p=0.79), intraoperative complications including adhesions (13% vs 12%, p&amp;gt;0.05) and empyema (27% vs 28%, p&amp;gt;0.05), as well as histological rate of chronic cholecystitis (88% vs 92%, p=0.68). Reasons associated with significantly delayed (&amp;gt;7 days) cholecystectomy after ERCP (n=12) include requiring coordination/consultation with other services prior to operation (3 subjects), prolonged course of gallstone pancreatitis (3 subjects), poor candidate for operation due to comorbidities (2 subjects), surgical cancellation/delays (2 subjects), post-ERCP pancreatitis (1 subject), and patient preference (1 subject). Image Conclusion(s) Early cholecystectomy is associated with a shorter length of hospital stay and absence of recurrent biliary events. Other post-cholecystectomy outcomes were comparable. Early laparoscopic cholecystectomy should continue to be encouraged through an interdisciplinary approach. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Use of doxorubicin-eluting bead transarterial chemoembolization for unresectable hepatocellular carcinoma with portal vein invasion: a prospective study.

To evaluate the applicability of transarterial chemoembolization (TACE) treatment with doxorubicin drug-eluting beads (DEBs) in advanced hepatocellular carcinoma (HCC) patients with portal vein invasion (PVI). This prospective study was approved by the institutional review board and informed consent was obtained from all participants. A total of 30 HCC patients with PVI received DEB-TACE between 2015 and 2018. The following parameters were evaluated: complications during DEB-TACE, abdominal pain, fever, and laboratory outcomes, including liver function change. Overall survival (OS), time to progression (TTP), and adverse events were also analyzed and assessed. DEBs measuring 100-300 μm in diameter were loaded with doxorubicin (150 mg per procedure). There were no complications during DEB-TACE and no significant differences in the levels of prothrombin time, serum albumin, or total bilirubin at follow-up compared to baseline. The median TTP was 102 days (95% confidence interval [CI], 42-207 days) and the median OS was 216 days (95% CI, 160-336 days). Three patients (10%) had severe adverse reactions, including transient acute cholangitis (n=1), cerebellar infarction (n=1), and pulmonary embolism (n=1), but no treatment-related death occurred. DEB-TACE may be a therapeutic option for advanced HCC patients with PVI.

A novel technique of endoscopic introducer-assisted transpapillary gallbladder aspiration prior to drainage in a patient with acute cholecystitis.

Endoscopic transpapillary gallbladder drainage (ET-GBD) is the preferred technique in patients with acute cholecystitis and cholangitis [1]. Meta-analyses have reported technical and clinical success rates of 83 % and 88.1 % respectively [1] [2]. Aspiration of the infected bile and saline irrigation using nasobiliary drainage is an acceptable method [1]; however, the performance of this maneuver during ET-GBD is time-consuming because of the high viscosity of the bile and the small caliber of the conventional endoscopic retrograde cholangiopancreatography catheter. Endoscopic introducer-assisted procedures have recently emerged as effective pancreaticobiliary interventions [3] [4]. This article describes gallbladder aspiration and irrigation using a novel dual-structure catheter.

Abstract No. 567 Safety and Efficacy of Percutaneous Management of Acute Cholangitis

Abstract No. 567 Safety and Efficacy of Percutaneous Management of Acute Cholangitis