Acute Suppurative Cholangitis Research Articles

Nomogram for assistant diagnosing acute suppurative cholangitis: a case-control study

BackgroundAcute suppurative cholangitis (ASC) lacks sensitive and specific preoperative diagnostic criteria. Some researchers suggest treating ASC as severe cholangitis. This study aimed to explore the relationship between the Tokyo Guidelines 2018 (TG18) grading system for acute cholangitis (AC) and the diagnosis of acute suppurative cholangitis (ASC), searching for independent risk factors of ASC and develop a nomogram to discriminate ASC from acute nonsuppurative cholangitis (ANSC) accurately.MethodsAfter applying the inclusion and exclusion criteria, 401 patients with acute cholangitis (AC) were retrospectively analyzed at Nanjing First Hospital between January 2015 and June 2023. SPSS version 27.0 and R studio software were used to analyze data obtained from medical records. The results were validated in a prospective cohort of 82 AC patients diagnosed at Nanjing First Hospital between July 2023 and February 2024.ResultsAmong the 401 patients, 102 had suppurative bile (the ASC group; AC grade I: 40 [39.2%], AC grade II: 27 [26.5%], AC grade III: 35 [34.3%]), whereas 299 did not have (the ANSC group; AC grade I: 157 [52.5%], AC grade II: 92 [30.8%], AC grade III: 50 [16.7%]). The specificity of ASC for diagnosing moderate-to-severe cholangitis is 79.7%. Multivariate logistic regression analysis identified concurrent cholecystitis, CRP, PCT, TBA, and bile duct diameter as independent risk factors for suppurative bile, and all of these factors were included in the nomogram. The calibration curve exhibited consistency between the nomogram and the actual observation, and the area under the curve was 0.875 (95% confidence interval: 0.835–0.915), sensitivity was 86.6%, and specificity was 75.5%.ConclusionSuppurative bile is a specific indicator for diagnosing moderate-to-severe cholangitis. However, diagnosing ASC with AC grade II and AC grade III has the risk of missed diagnosis as the sensitivity is only 60.8%. To improve the diagnostic rate of ASC, this study identified concurrent cholecystitis, CRP, PCT, TBA, and preoperative bile duct diameter as independent risk factors for ASC, and a nomogram was developed to help physicians recognize patients with ASC.

ERCP endoscopic minimally invasive treatment of acute suppurative obstructive cholangitis: A study of 47patients.

The primary objective of the present study was to investigate the efficacy and safety of endoscopic therapy for acute obstructive suppurative cholangitis (AOSC) in patients with different underlying conditions. The present study comprised 47 patients diagnosed with AOSC, with a mean age of 70±14 years. Minimally invasive endoscopic treatments, including endoscopic duodenal papillary sphincterotomy, endoscopic duodenal nasobiliary drainage and/or placement of an endobiliary duct stent drainage tube, were performed. Variations in the levels of the white blood cell count, liver function, procalcitonin (PCT) and carbohydrate antigen-199 (CA199) were examined, compared and evaluated both prior to and following endoscopic retrograde cholangiopancreatography (ERCP). Among the 47 patients, 45 had a high fever, although their body temperature returned to normal after 7 days of ERCP treatment. The infection was difficult to control completely in two cases, including one case of biliary anastomosis secondary tumor with stenosis and AOSC and another case of an elderly patient with multiple choledocholithiasis complicated with sepsis. Within 7 days following treatment, the abdominal pain was resolved in 27 patients and jaundice subsided in 29 patients. On the 7th day after endoscopic treatment, the blood leukocyte, liver function, PCT and CA-199 parameters of all patients were significantly improved compared with those at admission. A total of 35 bile cultures yielded positive results, with Escherichia coli accounting for 11 cases (31.4%), Klebsiella pneumoniae accounting for 7 cases (20%), Pseudomonas aeruginosa accounting for 5 cases (14.3%), Enterococcus faecus accounting for 4 cases (11.4%) and other strains making up the remaining 17 cases. No serious complications were encountered with these patients, such as perforation, bleeding, severe pancreatitis or mortality, following ERCP. In conclusion, ERCP has been shown to be a safe and effective minimally invasive treatment method for elderly patients with AOSC, yielding a high rate of success.

Acute suppurative terminal cholangitis: Clinical characteristics of a new subtype of acute cholangitis

BackgroundAcute suppurative terminal cholangitis (ASTC) is rarer than acute obstructive cholangitis and is not well studied. To explore this subtype of acute cholangitis, we described our clinical experience with ASTC. MethodsWe performed a retrospective review of patients with ASTC admitted to our center from September 2014 to August 2020. We analyzed their clinical characteristics, including etiology, clinical manifestations, imaging features, treatment and prognosis. ResultsA total of 32 ASTC patients were included in the analysis. The majority of the patients had a history of biliary operations, and clinical manifestations were occult and atypical. The positive rate of bacterial culture was 46.9%. All the patients had typical imaging features on computed tomography and magnetic resonance imaging. Treatment with effective antibiotics was provided as soon as diagnosis was established. After treatment, most patients had a good outcome. Elevated levels of total bilirubin, aspartate aminotransferase, procalcitonin and gamma-glutamyltransferase were the characteristics of critically ill patients and were associated with relatively poor prognosis. ConclusionsOur results demonstrated that ASTC should be recognized as a new subtype of acute cholangitis, and that earlier diagnosis and more personalized treatments are needed.

Efficacy of ultrasound-guided percutaneous transhepatic biliary drainage for acute obstructive suppurative cholangitis combined with septic shock

ObjectivesThis study aimed to investigate the efficacy of ultrasound-guided Percutaneous Transhepatic Biliary Drainage (PTCD) for the treatment of Acute Obstructive Suppurative Cholangitis (AOSC) combined with septic shock due to choledocholithiasis, and its effect on inflammatory factors. MethodsClinical data of 86 patients with AOSC and septic shock admitted to our hospital between January 2019 and May 2021 were retrospectively analyzed and grouped according to different treatment methods. Among them, 43 patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Nasobiliary Drainage (ENBD) were included in the Control Group (CNG), and 43 patients who underwent ultrasound-guided PTCD were included in the Study Group (SG). ResultsThe total effective rate in the SG (88.37%) was higher than that in the CNG (69.77%) (p < 0.05); after surgery, the serum inflammatory factors PCT, IL-6, TNF-α, CRP levels, liver function indicators such as TBIL, DBIL, AST, ALT levels, and stress response indicators including NPY, PGE2, 5-HT levels were reduced, and were lower in the SG than in the CNG (p < 0.05); postoperatively, CD3+, CD4+, and CD4+/CD8+ levels in the CNG were significantly lower than those before surgery (p < 0.05); Postoperatively, CD3+, CD4+, and CD4+/CD8+ levels in the SG were significantly higher than those in the CNG (p < 0.05); and the complication rate in the SG (6.98%) was lower than that in the CNG (25.58%) (p < 0.05). ConclusionsUltrasound-guided PTCD for AOSC combined with septic shock can facilitate the recovery of liver and immune functions with a low complication rate.

Unusual biliary gem: Cause of acute obstructive suppurative cholangitis and pancreatitis in a patient with Billroth II anastomosis

A 72-year-old man with a 10-year history of subtotal gastrectomy with Billroth II anastomosis and laparoscopic cholecystectomy presented with abdominal pain, high fever and altered mental status. His blood pressure was 94/50mmHg, heart rate 136bpm and body temperature 39.4°C. Laboratory examination revealed the following: white blood cell count 16,200/μL; aspartate aminotransferase 418IU/L; alanine aminotransferase 160IU/L;

Hyperbilirubinemia 73 mg/dl after Acute Suppurative Cholangitis is not always ‎Fatal, a Case Report

Hyperbilirubinemia 73 mg/dl after Acute Suppurative Cholangitis is not always ‎Fatal, a Case Report

Laparoscopic Bile Duct Exploration Technique

Common bile duct stone is a relatively frequent disorder with a prevalence of 15 to 20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment are the most important for managing CBD stones. Various approaches of laparoscopic CBD exploration plus primary duct closure are the most commonly used and the best methods to treat CBD stone. We prefer not to use a T tube when performing a Common bile duct exploration, instead, the primary closure or the use of biliary stents is more suitable.

A case of severe hypothermia with acute suppurative cholangitis resulting in bradycardia and cardiac arrest during rewarming

A case of severe hypothermia with acute suppurative cholangitis resulting in bradycardia and cardiac arrest during rewarming

Hyperbilirubinemia 73mg/Dl After Acute Suppurative Cholangitis is Not Always Fatal, a Case Report

Hyperbilirubinemia 73mg/Dl After Acute Suppurative Cholangitis is Not Always Fatal, a Case Report

The role of periampullary diverticulum on the incidence of pancreaticobiliary diseases and the outcome of endoscopic retrograde cholangiopancreatography.

IntroductionPeriampullary diverticulum (PAD), although commonly discovered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), remains controversial regarding its role in pancreaticobiliary diseases and the failure rate of cannulation. The aim of this study was to evaluate the association of PAD with pancreaticobiliary diseases and its impact on the outcome of ERCP.Material and methodsA retrospective analysis was carried out on 1455 patients who underwent an ERCP. Patients were divided into a PAD group and a control group without PAD, and propensity score matching was performed to adjust for clinical differences. The comparison was focused on pancreaticobiliary diseases, technical success, and complications of ERCP.ResultsThe occurrence of PAD is associated significantly with increasing age (p < 0.001). Incidences of acute pancreatitis (AP), suppurative cholangitis, and pancreatic head cancer were significantly higher in the PAD group (p < 0.05). After propensity score matching, the PAD group exhibited a higher rate of post-ERCP complications including haemorrhage, post-ERCP pancreatitis (PEP), and hyperamylasaemia (p < 0.05). However, the prevalence of perforation and the success rate of ERCP did not differ between groups (p > 0.05).ConclusionsPeriampullary diverticulum develops with aging and seems to be associated with an increase in pancreaticobiliary diseases and post-ERCP complications except for perforation. Additionally, the presence of PAD does not affect the technical success of ERCP.

ИЗМЕНЕНИЕ ФИЗИКО-ХИМИЧЕСКИХ СВОЙСТВ ЖЕЛЧИ В ПРОЦЕССЕ ВОЗНИКНОВЕНИЯ И МАНИФЕСТАЦИИ ХОЛАНГИТА. ОСТРЫЙ ХОЛАНГИТ: ВОЗМОЖНЫЕ МЕХАНИЗМЫ ЗАПУСКА

Objective. To determine the possible triggering mechanism for the development and manifestation of acute suppurative cholangitis based on the study of the rheological, physical and chemical properties of bile. Methods. The bile of choledoch was studied inpatients (n=41) with calculous obstruction of the biliary tract, 25 of them had clinical picture of cholangitis. For comparison, 32 patients with asymptomatic choledocholithiasis were examined. Bile sampling was performed in each patient twice: the first bile intake was obtained during duodenoscopy and cannulation of the major papilla of the duodenum and endoscopic papillosphincterotomy and the second portion - during a follow-up examination three days after the endoscopic papillotomy. The biliary pH, viscosity, the amount of solids in it, the concentration of primary bile acids, microbial contamination and the intraductal pressure were studied. Results. For the first time, it has been hypothesized that a reduced concentration of bile acids in the bile causes a subsequent chain of triggering and manifestation of acute cholangitis. In the first bile intake the concentration of bile acids is three fold decreased in patients with acute cholangitis in comparison with the patients of control group, and in the second case it reliable increased but was lower than in the control group. It was a small amount of bile acids caused sedimentation of a colloidal bile solution, increased its viscosity and amount of dry sediment, caused precipitation and sludge. This chain process caused the instantaneous inclusion of concretion in sludge and acute obstruction of the choledoch. As a result of bacterial contamination, the microbial dissemination of bile increases by 10&lt;sup&gt;3&lt;/sup&gt;-10&lt;sup&gt;4&lt;/sup&gt; times, the choledoch becomes like an abscess. Endoscopic papillosphincterotomy breaks this chain and surgical management is the definitive mode of treatment for decompression and biliary track sanitation. Conclusion. A decrease of bile acids in the content of the bile causes a chain process of sedimentation, the formation of sludge and a complete block of the choledoch, which is the primary trigger for cholangitis. What this paper adds Scientific and theoretical principles which in their essencedetermine the possible mechanism of the development of cholangitis due to choledocholithiasis have been developed. The physicochemical properties of bile play a decisive role in the triggering mechanism of cholangitis. Reduction of the synthesis of bile acids in the liver or their resorption in the intestine starts an avalanche-like process of sedimentation in the micellar solution of bile in the choledoch, sludge with the stones appears, the pH decreases, intraductal pressure rises, as a result of bacterial infection microbial contamination the microbal dissemination increases by 10&lt;sup&gt;3&lt;/sup&gt;-10&lt;sup&gt;4&lt;/sup&gt; fold.

A retrospective study on 1 152 patients with common bile duct stones

Objective To analyze the incidence of choledocholithiasis in patients who underwent cholecystectomy in our hospital, and to determine the incidences of recurrent stones and choledocholithiasis combined with cholangitis after treatment for choledocholithiasis. Methods A retrospective study was conducted on 1 152 patients with common bile duct stones treated from January 2013 to July 2017 in our hospital. Results Of the 1152 patients with common bile duct stones, 572 patients had a history of cholecystectomy, accounting for 49.65% of all patients. 402 patients had choledocholoithiasis combined with cholecystolithiasis (34.9% of all patients), 278 patients had choledocholithiasis without cholecystolithiasis (24.1%). Choledocholithiasis could occur after cholecystectomy. The time of onset of choledocholithiasis was 5~10 years after operation in 49.1% of patients, and 200 of these patients with choledocholithiasis were treated with lithotripsy. There were 110 patients who underwent choledocholithotomy and cholecystectomy, and 90 patients who underwent ERCP and stone removal. There was no significant difference between the 2 groups (P>0.05). Choledocholithiasis complicated with cholangitis developed in 511 patients (44.3% of all patients). These included 437 patients with acute mild cholangitis (85.5%) and acute obstructive suppurative cholangitis (14.5%). Recurrent choledocholithiasis combined with acute cholangitis after choledocholithotomy developed in 51 patients, and recurrent choledocholithiasis combined with cholangitis developed after ERCP in 50 patients. There was no significant difference between the two groups (P>0.05). Conclusions Choledocholithiasis after cholecystectomy accounted for a high proportion of patients. Recurrent choledocholithiasis could occur after choledocholithotomy. Common bile duct stones were susceptible to develop cholangitis. Thus, common bile duct stones should be treated as soon as possible. Key words: Common bile duct stones; Cholecystectomy; Cholangitis; Cholangiopancreatography, endoscopic retrograde

Mo1664 ENDOSCOPIC INTERVENTION FOR ACUTE APPENDICITIS——RETROSPECTIVE STUDY OF 101 CASES

Acute appendicitis is the most common cause for acute abdominal surgery in clinics. Appendectomy is the standard strategy for acute appendicitis over one century. Some postoperative complications are inevitable, such as incision infection, abdominal infection and bowel obstruction. Appendix has been recognized as the important part of immune system. Precise diagnosis and treatment of acute appendicitis need clinical advances. Endoscopic retrograde appendicitis therapy (ERAT) was developed to diagnose and treat acute appendicitis. ERAT procedure was similar to endoscopic retrograde cholangiopancreatography (ERCP) for acute suppurative cholangitis. This study intended to share our clinical findings and therapeutic experience during its application.

Simplified scoring system for prediction of mortality in acute suppurative cholangitis

Our objective in this study was to identify the factors contributing to mortality in acute suppurative cholangitis which could be tested easily in every emergency clinic. This is a retrospective study enrolling 104 patients with acute suppurative cholangitis. Demographic and laboratory data were collected for analysis. In univariant analysis red cell distribution width, total bilirubin level, intensive care unit admission was identified as statistically significant (p < 0.05) to predict mortality. Three variables were statistically significant in multivariate analysis: total bilirubin level equal to or more than 6.9 mg/dl, red cell distribution width equal to or more than 14.45%, and admission to intensive care unit. We found a new scoring system for prediction of mortality in acute suppurative cholangitis utilizing only three variables. This would serve as a simplified, rapid way to direct patients for advanced interventions instead of wasting time with more complicated and time consuming multi-variable scoring systems.

The Management of Common Bile Duct Stones

Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10-20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.

Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis

Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis

Changes of Foxo3a in PBMCs and its associations with stress hyperglycemia in acute obstructive suppurative cholangitis patients.

ObjectiveThe levels of Foxo3a in the peripheral blood mononuclears cells (PBMCs) before and after treatment were detected in acute obstructive suppurative cholangitis (AOSC) patients to evaluate the associations between Foxo3a and stress hyperglycemia (SHG).MethodsPBMCs were obtained from AOSC patients (n=28) on admission (AP), from patients at 1 week after cure (RP) and from healthy volunteers (HV) (n=14) to evaluate the relationship between the protein levels of Foxo3a and the serum levels of glucose. Signaling pathways, which link inflammation and glycometabolism, simultaneously affecting the expression of Foxo3a, were detected. In addition, cytokines were detected in PBMCs and AOSC mouse models, which were pre-treated with Foxo3a agonist.ResultsThe levels of glucose and p-Foxo3a in the AP were significantly higher than those in the RP and HV, where as the levels of Foxo3a in the AP were lower than those in the RP and HV. Foxo3a levels in the AP normalized against RP were strongly negatively correlated with the glucose levels in the AP normalized against RP. The levels of sphingosine-1-phosphate receptor 2 (S1PR2) in the AP were higher than those in the RP and HV. In addition, inhibition of Foxo3a phosphorylation, coupled with the down-regulation of S1PR2, attenuated the LPS-induced inflammatory response in the PBMCs and AOSC mouse models.ConclusionsFoxo3a is correlated with the dysregulation of glucose homeostasis in the pathogenesis of AOSC-induced sepsis by inhibiting the activation of PI3K/Akt-S1PR2 and NF-κB pathways, hinting at a switched role and therapeutic potentialities in the early stage of sepsis.

Emergency endoscopic treatment of acute obstructive suppurative cholangitis

Objective To determine the best endoscopic treatment for acute obstructive suppurative cholangitis(AOSC). Methods Data of 93 patients who were diagnosed as having AOSC in endoscopic center in the last three years were retrospectively analyzed. All patients were divided into three groups according to the different treatment methods: ENBD group, ENBD+ ERBD group and double ERBD group. Postoperative temperature, bilirubin levels and mortality were compared. Results For patients with high level obstruction, incidence of fever in ENBD+ ERBD group and double ERBD group were significantly higher than that of ENBD group(1/18 VS 4/10, P<0.05; 0 VS 4/10, P<0.05). There were no significant differences in incidence of fever(1/18 VS 0) or bilirubin level decrease (17/18 VS 14/15) between ENBD+ ERBD group and double ERBD group. For high level obstruction, if the patient had biliary imaging with contrast medium during operation, they would have higher incidence of high fever[(4/10 VS 3.45%(1/28)] and mortality(3/11 VS 0), lower declining rate of bilirubin level [10/14 VS 96.55%(28/29)] than those without. Conclusion Both left and right hepatic ducts drainage should be recommended for high level biliary obstruction. During the operation, contrast medium should be limited to minimum dose, and should be avoided in high level obstruction cases. Air biliary imaging could be used when necessary. Key words: Emergency; Cholangitis; Endoscopic therapy

Intraoperative endoscopic nasobiliary drainage over primary closure of the common bile duct for choledocholithiasis combined with cholecystolithiasis: a cohort study of 211 cases

Endoscopic nasobiliary drainage (ENBD) was often used for preoperative biliary drainage in cases like cholangiocarcinoma or acute obstructive suppurative cholangitis, reports on endoscopic nasobiliary drainage (ENBD) over primary closure of the common bile duct (CBD) are limited. This study compares outcomes of laparoscopic cholecystectomy (LC)+laparoscopic CBD exploration (LCBDE)+intraoperative ENBD+primary closure of CBD with equivalent patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and subsequent LC. From January 2013 to December 2015, 829 consecutive patients with choledocholithiasis combined with cholecystolithiasis underwent surgery in our department. 211 patients underwent LC+LCBDE+intraoperative ENBD+primary closure of CBD (group A) and 117 preoperative ERCP+subsequent LC (group B). A total of 501 patients (355 who underwent T-tube drainage and 146 who underwent transcystic exploration) were excluded from the analysis. Clinical records, operative findings, and postoperative follow-up were analyzed. Age and sex distribution, comorbidity, presentations, CBD diameter, and size and number of stones were similar in the two groups, and there was no postoperative mortality. Duration of surgery in group A was shorter (83 vs. 104min, P<0.01), as was postoperative hospital stay (6 vs. 9days, P<0.01). Average operative expenditure in group A was less than that of group B ($ 3816 vs. $ 4015, P<0.01). The success rate in group A was higher (100 vs. 91%, P<0.01). Ten patients in group B converted to LCBDE. The postoperative complication rate was higher in group B but without significant difference (1.9 vs. 4.2%, P=0.29). Median follow-up time was 24 (3-28) months (n=302 patients). Two patients in group B reported residual stones. LC+LCBDE+intraoperative ENBD+primary closure of CBD should have priority over preoperative ERCP+subsequent LC for choledocholithiasis combined with cholecystolithiasis.

A Case of Acute Suppurative Cholangitis Caused by a Carbapenem-Resistant Aeromonas hydrophila/caviae

A Case of Acute Suppurative Cholangitis Caused by a Carbapenem-Resistant Aeromonas hydrophila/caviae