Acute Obstructive Cholangitis Research Articles

Effects of biliary tract pressure on dynamics of the Oddi's sphincter and its nerve mechanism.

In order to explore the effect of biliary tract pressure on Oddi's sphincter and the mechanism of development of high pressure of biliary tract during acute obstructive and suppurative cholangitis (AOSC), house rabbits were used to establish model of high biliary pressure in acute biliary duct caecus. It was observed that when the pressure of the acute biliary tract was increased to 8 kPa, the electric activity of Oddi's sphincter was obviously enhanced, the pressure of Oddioes sphincter increased remarkably (P < 0.05), and even constant spasm appeared with accompanying increase of discharge frequency of the right greater splanchnic nerves (P < 0.05) and progressive decrease of mean arterial pressure. However, when lidocaine of 0.6% was used to block the right celiac plexus, no above-mentioned reaction happened when the biliary tract pressure was increased again. The results indicated that the acute biliary tract obstruction might induce the contraction or spasm of Oddi's sphincter and bring about a vicious cycle. Its mechanism is related to splanchnic nerves reflection and it is one of important factors in the development of AOSC course.

Endoscopic biliary drainage for acute obstructive cholangitis: Effects of bilionasal drainage and stent placement

Acute obstructive suppurative cholangitis is a life-threatening condition which requires prompt biliary decompression. A retrospective review of 92 patients with acute obstructive suppurative or nonsuppurative cholangitis (46 men and 46 women with a mean age of 65.1 years) was conducted. All patients had undergone endoscopic biliary decompression by retrograde cannulation with (79 patients) or without (13 patients) sphincterotomy. Nineteen patients had received sphincterotomy previously. In addition to biliary decompression, 48 of the 92 patients had a bilionasal catheter or a stent placed in the common bile duct (group A), while the other 44 patients did not (group B). The effect of drainage was successful in 83 of the 92 patients (90%), but 1 patient in group A died of liver failure due to advanced cirrhosis of the liver despite successful drainage; thus, the overall mortality rate was 1.1%. Although the mortality and overall morbidity rates (2.1% and 42% in group A, and 0% and 34% in group B, respectively) did not differ between the two groups, the frequency of recurrent cholangitis was significantly higher in group B (60%) than in group A (4.2%) (P<0.001). We conclude that endoscopic biliary decompression is a prompt, safe, and effective method for the treatment of acute obstructive cholangitis. We stress that a stent or a bilionasal drainage catheter should always be placed if recurrent cholangitis is to be prevented until complete clearance of the stones is achieved.

Pathophysiology of acute obstructive cholangitis

Because acute obstructive cholangitis is life-threatening, understanding of the pathophysiology of this disease is required to establish a medical treatment. Experimental results indicate that obstruction of the bile duct itself does not induce acute cholangitis, but infection of gut-derived bacteria such asEscherichia coli into the bile triggers fatal septicemia, which leads to liver injury and renal failure. In obstructive cholangitis, functional changes in sinusoidal lining cells are often seen. Mediators produced by Kupffer cells, endothelial cells, and stellate cells may modulate inflammatory reactions especially in the periportal area of bile duct ligated animals. In addition, proliferation of bile duct epithelial cells is induced by bile duct ligation. Recently, nitric oxide has been recognized as an important mediator of multiple organ failure. Actually, when bile duct ligated animals are treated with endotoxin, metabolites of nitric oxide in blood and plasma increase, indicating that nitric oxide may take part in the pathophysiology of acute obstructive cholangitis.

Macrophages and Neutrophils Infiltrating into the Liver Are Responsible for Tissue Factor Expression in a Rabbit Model of Acute Obstructive Cholangitis

Acute obstructive cholangitis (AOC) is one of the most fatal outcomes in sepsis, and frequently complicates disseminated intravascular coagulation (DIC). Recently we found that the plasma tissue factor (TF) level increased and changed in parallel with plasma markers of DIC in patients with AOC. To elucidate the role of TF in the pathogenesis of coagulopathy in AOC, we investigated the plasma levels of TF and its localization by immunohistochemical staining in rabbit models of AOC. Plasma TF activity significantly increased 3 h after the insult (0.63 +/- 0.1¿9 U/ml; p < 0.01) compared with that beforehand (0.05 +/- 0.02 U/ml), then reached a maximum level at 6 h (0.94 +/- 0.16 U/ml). The fluctuations in plasma TF activity correlated with those of the coagulation parameters including platelet count, fibrinogen, prothrombin time, and antithrombin III activity. Immunohistochemically, enhanced expression of TF was mainly detected in macrophages and neutrophils that had infiltrated into the liver sinusoids and around the bile duct, but not in the sinusoidal endothelial cells. A double immunofluorescence study revealed the concomitant presence of TF and fibrin at sites where macrophages and neutrophils had conglomerated. However, we could not detect an apparent change in TF expression in the lung or kidney. These data suggest that macrophages and neutrophils infiltrating into the liver sinusoids and around the bile duct play a pivotal role in TF expression, leading to coagulopathy in the acute phase of obstructive cholangitis in rabbits.

Successful management of preoperative cholangitis by percutaneous transhepatic biliary drainage: Case report of advanced gallbladder carcinoma with severe cholangitis

A case of advanced gallbladder carcinoma complicated with preoperative severe cholangitis is reported. The cholangitis was completely controlled after management employing percutaneous transhepatic biliary drainage (PTBD), and it was then possible to perform curative resection of the gallbladder carcinoma. Malignancy at the hepatic hilus sometimes causes acute obstructive cholangitis, followed by severe liver dysfunction, making major hepatic resection impossible. PTBD is quite useful for improving such a pathological condition.

Multiple Organ Failure on Acute Obstructive Supprative Cholangitis

Multiple Organ Failure on Acute Obstructive Supprative Cholangitis

Studies on the antibiotic transfer into the bile of canines with different bile duct pressures.

There have been many studies on the transport of antibiotics into the bile; however, these studies have not taken the bile duct pressure into consideration. The bile duct pressure of the patient with acute obstructive cholangitis is high, and after drainage of the bile, the pressure is not always decreased to the normal range. We studied the effects of the bile duct pressure on the antibiotic (flomoxef sodium) transfer into the bile using beagles after creating the model of acute obstructive cholangitis. Our results showed that sufficient bile flow after drainage is important for the antibiotic transport, and, moreover, the bile acid concentration which may be related to the bilirubin concentration is also highly considerable.

Endoscopic Biliary Drainage for Acute Obstructive Cholangitis: Analysis of 100 Consecutive Patients

Abstract: Acute obstructive suppurative cholangitis is a life‐threatening condition and prompt biliary decompression is essential if the patient is to survive. One hundred patients with acute obstructive (suppurative) cholangitis were treated by simple endoscopic cannulation for biliary drainage. Forty‐eight patients had common duct stones alone, 33 patients had additional stones in the gallbladder, and 18 patients had stones in the intrahepatic ducts. Another patient had a confluence stone. Twenty‐six patients had undergone endoscopic sphincterotomy. Bile duct dilatation was present in only 25 of 47 patients (53%) studied by ultrasound tomography. Biliary decompression was achieved in 98 patients. One tortuous distal bile duct and one oversized stone were the causes of failure in two patients. Forty‐seven patients proved to have suppurative cholangitis. Most patients felt instant and dramatic relief of their syniptoms. Bleeding at sphinctetomy was the only complication associated with the decompression ocurring in 2 patients. Bending (2 patients) and withdrawal (2 patients) of a nasobiliary catheter, and nasal bleeding (1 patient) were the complications related to nasobiliary drainage. Two patients with suppurative cholangitis died despite successful decompression performed 3 and 5 days after the onset of cholangitis. This delay seemed responsible for their deaths. Thus the mortality rate was 2.0% for all the patients arid 4.3% for those with suppurative cholangitis. These results suggest that endoscopic cannulation, which is feasible even in the absence of bile duct dilatation, is a prompt, safe, and effective procedure for emergency biliary decompression for the treatment of acute obstructive (suppurative) cholangitis.

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.

Ultrasonically-guided percutaneous transhepatic gallbladder puncture for acute cholecystitis and percutaneous transhepatic gallbladder drainage for acute obstructive cholangitis

Ultrasonically-guided percutaneous transhepatic gallbladder puncture for acute cholecystitis and percutaneous transhepatic gallbladder drainage for acute obstructive cholangitis

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.

治療に難渋した肝内結石症の一症例

A case of left intrahepatic lithiasis with acute obstructive cholangitis and endotoxin shock was reported.This patient was 37-year-old woman, who visited our hospital complaining of abdominal pain, fever and jaundice. The operation, cholecystectomy and T-tube drainage, was performed, but lithotomy of left intrahepatic duct stones was not performed, because of shock stadium.The residual stones could be all removed by post operative cholangioscopic laser lithotomy and by endoscopic papillotomy and cholangioscopic papillotomy, Nd-YAG laser was used for lithotomy and its irradration time were 5 times. Stones were removed perfectory.

Percutaneous biliary drainage in the management of biliary sepsis.

Percutaneous biliary drainage was performed in 18 patients with biliary sepsis due to acute obstructive cholangitis and postoperative complications. Internal drainage could be established in 78% of patients, and 22% were managed on external drainage. Nine patients were managed on long-term internal drainage, six underwent uneventful surgery after successful percutaneous decompression, and three died as a result of septic shock. Percutaneous biliary drainage procedures can be lifesaving in biliary sepsis. Once infection and the hyperbilirubinemia are controlled, rational therapy plans can be formulated on the basis of the anatomy and natural history of the underlying disease.

Cholangitis With a Silver Lining

Acute obstructive cholangitis developed secondary to a common duct stone formed around a silver hemostatic clip, introduced at cholecystectomy two years previously, that had migrated from a long cystic duct remnant. Stone formation around a silk suture is well known, and silver clips in the area of the porta hepatis may constitute a similar hazard.

ACUTE OBSTRUCTIVE CHOLANGITIS.

ACUTE obstructive cholangitis is a clinical syndrome characterized by right upper abdominal pain, jaundice, chills with fever (Charcot's triad), central nervous system signs such as lethargy, disorientation, or coma, combined with septic shock. Reynolds and Dargan in 1959 emphasized this clinical pentad as a distinct entity which if untreated results in a high mortality rate.1An awareness of this syndrome leading to early recognition and prompt surgery will offer the best opportunity for survival. Acute inflammation of the biliary tree has been recognized since Charcot's original description in 1877.2Osler in 1890 stressed that Charcot's fever was irregular and of short duration.3In 1899 in necropsy studies Rogers recognized the role of surgical intervention in acute suppurative cholangitis.4He unsuccessfully performed surgical decompression of the common duct by utilizing a glass tube on a patient with this disease. In 1940 Cutler and Zollinger stressed the need

Serum Vitamin B12 and Glutamic-Oxalacetic Transaminase in Experimental Intrahepatic Obstructive Jaundice

Summary A single dose of α-naphthyl-isothiocyanate (ANIT) caused in white rats, within 1 to 2 days, acute intrahepatic obstructive cholangitis. The histologic changes were accompanied by a rise in bilirubin, total cholesterol, and alkaline phosphatase levels in the serum. A marked rise of serum glutamic-oxalacetic transaminase (GOT) and a substantial depletion of liver GOT were found during the first 48 hours after the administration of ANIT. The level of vitamin B 12 in the serum remained within normal limits except for a slight fall by the end of the first week. Although the histologic changes had mostly regressed by the end of the first week, the biochemical changes disappeared gradually within 3 to 4 weeks. The markedly raised serum GOT at the height of the jaundice appears to be of hepatic origin. In view of the only minor morphologic changes of the liver cells and the normal levels of vitamin B 12 in the serum, it is assumed that enzyme may escape from intact liver cells in the presence of obstruction to biliary drainage.

Acute obstructive cholangitis; a distinct clinical syndrome.

Acute obstructive cholangitis; a distinct clinical syndrome.