Biliary Drainage For Acute Cholangitis Research Articles

Endoscopic retrograde cholangiopancreatography-obtained bile culture in acute cholangitis: retrospective analysis of bile cultures and risk factors in a tertiary care center.

Collection of bile aspirate during endoscopic retrograde cholangiopancreatography (ERCP) is essential to identify pathogens responsible for acute cholangitis. Limited data are available on the risk factors for the presence of multidrug-resistant organisms (MDRO) in bile. We conducted this retrospective, single-center study to assess the prevalence and susceptibility rates of bacteria in bile cultures, and the risk factors for the presence of pathogens, MDRO, and fungi in bile. All consecutive patients who underwent biliary drainage for acute cholangitis from January 2017 to December 2019 were included. 443/1610 ERCPs were performed for acute cholangitis. Bile culture was collected in 91.4% (405/443), of which 86.7% were positive. Most common isolates were Enterococcus faecalis (37.6%) and Escherichia coli (32.8%). Vancomycin resistance was found in 9.9% of Enterococcus species (spp.); extended-spectrum beta-lactamases (ESBL) and carbapenemases in 11.2% and 0.9% of Enterobacteriaceae, respectively. The empiric antimicrobial therapy was changed in 26.4% (n=107) of cases, with a clinical response in 90.7%. In multivariate analysis, biliary stenting was an independent risk factor for positive bile culture (odds ratio [OR] 9.43; P<0.01). Independent risk factors for MDRO in bile were patient age>60years (OR 2.51; P=0.03), previous sphincterotomy (OR 2.57; P=0.02), and biliary stenting (OR 2.80; P<0.01). Previous sphincterotomy was the only risk factor for isolation of fungi in bile (OR 1.61; P=0.04). Our study showed an increasing prevalence of Enterococcus spp. and MDRO. Bile cultures should be routinely collected in cholangitis and in patients with repeated ERCPs to allow more efficient antimicrobial treatment.

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.

Neutrophil-lymphocyte Ratio Predicts Clinical Response to Percutaneous Transhepatic Biliary Drainage in Acute Cholangitis

Predicting response to biliary drainage is critical to stratify patients with acute cholangitis. Total leucocyte count (TLC) is one of the criteria for predicting the severity of cholangitis and is routinely performed. We aim to investigate the performance of neutrophil-lymphocyte ratio (NLR) in predicting clinical response to percutaneous transhepatic biliary drainage (PTBD) in acute cholangitis. This retrospective study comprised consecutive patients with acute cholangitis who underwent PTBD and had serial (baseline, day 1, and day 3) TLC and NLR measurements. Technical success, complications of PTBD, and clinical response to PTBD (based on multiple outcomes) were recorded. Univariate and multivariate analysis was performed to identify factors significantly associated with clinical response to PTBD. The sensitivity, specificity, and area under the curveof serial TLC and NLR for predicting clinical response to PTBD were calculated. Forty-five patients (mean age 51.5 years, range 22-84) met the inclusion criteria. PTBD was technically successful in all the patients. Eleven (24.4%) minor complications were recorded. Clinical response to PTBD was recorded in 22 (48.9%) patients. At univariate analysis, the clinical response to PTBD was significantly associated with baseline TLC (P= 0.035), baseline NLR (P=0.028), and NLR at day 1 (P=0.011). There was no association with age, the presence of comorbidities, prior endoscopic retrograde cholangiopancreatography, admission to PTBD interval, diagnosis (benign vs. malignant), severity of cholangitis, organ failure at baseline, and blood culture positivity. At multivariate analysis, NLR-1 independently predicted the clinical response. Area under the curve of NLR at day 1 for predicting clinical response was 0.901. NLR-1 cut-off value of 3.95 was associated with sensitivity and specificity of 87% and 78%, respectively. TLC and NLR are simple tests that can predict clinical response to PTBD in acute cholangitis. NLR-1 cut-off value of 3.95 can be used in clinical practice to predict response.

Current status of biliary drainage for acute cholangitis

Current status of biliary drainage for acute cholangitis

Clinical Outcomes of Early Endoscopic Transpapillary Biliary Drainage for Acute Cholangitis Associated with Disseminated Intravascular Coagulation.

Acute cholangitis (AC) is often associated with disseminated intravascular coagulation (DIC), and endoscopic transpapillary biliary drainage (EBD) under endoscopic retrograde cholangiopancreatography (ERCP) is a treatment of choice. However, no evidence exists on the outcomes of EBD for AC associated with DIC. Therefore, we retrospectively evaluated the treatment outcomes of early EBD and compared endoscopic biliary stenting (EBS) and endoscopic nasobiliary drainage (ENBD). We included 62 patients who received early EBD (EBS: 30, ENBD: 32) for AC, associated with DIC. The rates of clinical success for AC and DIC resolution at 7 days after EBD were 90.3% and 88.7%, respectively. Mean hospitalization period was 31.7 days, and in-hospital mortality rate was 4.8%. ERCP-related adverse events developed in 3.2% of patients (bleeding in two patients). Comparison between EBS and ENBD groups showed that the ENBD group included patients with more severe cholangitis, and acute physiology and chronic health evaluation II score, systemic inflammatory response syndrome score, and serum bilirubin level were significantly higher in this group. However, no significant difference was observed in clinical outcomes between the two groups; both EBS and ENBD were effective. In conclusion, early EBD is effective and safe for patients with AC associated with DIC.

Impact of the Sensitivity to Empiric Antibiotics on Clinical Outcomes after Biliary Drainage for Acute Cholangitis.

Background/AimsEmpiric antibiotics are given in combination with biliary drainage for acute cholangitis but sometimes turn out to be insensitive to microorganisms in blood and bile. Clinical outcomes were compared according to sensitivity to microorganisms detected in blood and bile culture to evaluate the impact of sensitivity to empiric antibiotics in cholangitis.MethodsConsecutive patients who underwent biliary drainage for acute cholangitis were retrospectively studied. Clinical outcomes such as 30-day mortality, length of hospital stay and high care unit stay, organ dysfunction and duration of fever were compared in three groups group A (sensitive to both blood and bile culture), group B (sensitive to blood culture alone) and group C (insensitive to both blood and bile culture).ResultsEighty episodes of cholangitis were classified according to sensitivity results 42, 32 and six in groups A, B and C. Escherichia coli and Klebsiella were two major pathogens. There were no significant differences in 30-day mortality rate (7%, 0%, and 0%, p=0.244), length of hospital stay (28.5, 21.0, and 20.5 days, p=0.369), organ dysfunction rate (14%, 25%, and 17%, p=0.500), duration of fever (4.3, 3.2, and 3.5 days, p=0.921) and length of high care unit stay (1.4, 1.2, and 1.7 days, p=0.070) in groups A, B and C. Empiric antibiotics were changed in 11 episodes but clinical outcomes appeared to be non-inferior even in 31 episodes of cholangitis who were on inadequate antibiotics throughout the course.ConclusionsSensitivity of empiric antibiotics was not associated with clinical outcomes in acute cholangitis.

Endoscopic Biliary Drainage for Acute Cholangitis in the Elderly

Endoscopic Biliary Drainage for Acute Cholangitis in the Elderly

Endoscopic management of acute cholangitis according to the TG13.

The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future.

ERCP for Septic Cholangitis Through a Peg Tube, a Life-Saving Procedure Using an Alternative Access Route to Approach the Biliary Tree When the Regular ERCP Fails

Acute cholangitis, is a product of bile stasis and infection of the biliary tract. Diagnostic and therapeutic role of the Endoscopic retrograde cholangiopancreatography (ERCP) has a critical role in the management. Anatomical variation following Roux-en-Y gastric bypass or people who had esophageal obstructions tend to make the early intervention by the ERCP a challenge. We report a case of septic cholangitis in a patient whom the ERCP was achived through a peg tube. Case report: 75-year-old male esophageal cancer & gastrostomy tube for malnutrition presented to the local hospital with fevers. Initial evaluation showed feature of sepsis with a fever, leukopenia, elevation in the liver enzymes & total bilirubin 1.2 and lactic acid 3.2. Ct scan showed a stone in the common bile duct & blood cultures showed Enterobacter cloacae. The patient started on ceftriaxone & transferred to our tertiary center for therapeutic intervention. The patient had a MRCP that demonstrates a 1.3 cm obstructive distal common bile duct stone for which the patient underwent an attempt with ERCP that shortly aborted given partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be pass the mass but the procedure terminated due to scope malfunction. Another route to access the biliray system was found; the peg tube was removed after an anchoring system was placed. Following the placement of the anchors an Axio stent was placed & a balloon dilitation was performed inside the stent up to 15 mm in size. Following dilitation an ERCP scope was placed and the papilla was accessed and sphincterotomy was made and stone was removed. After the stone removal, the stent was removed and a peg tube was replaced and the patient tolerated the procedure without any complication & discharged on stable condition. Discussion: ERCP is the treatment of choice in establishing biliary drainage in acute cholangitis. In the setting of anatomical variation, the success rate dramatically dropped below 70% when compare it to the traditional ERCP 90-95%. The literature showed that the success rate is higher using surgically created route through the stomach as a mature gastrostomy, trans-gastric or laproscopic- assisted port are all well tolerated. In patient with limited access for the traditional ERCP, alternative routes can allow the gastroenterologist to drain the blockage; such intervention can improve the mortality & morbidty.

TG13 indications and techniques for biliary drainage in acute cholangitis (with videos)

The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Treatment Outcome of Endoscopic Biliary Drainage for Acute Cholangitis Due to Bile-Duct Stones

Treatment Outcome of Endoscopic Biliary Drainage for Acute Cholangitis Due to Bile-Duct Stones

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system. A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases). Significant variation in mean LOS was observed between hospital volume categories (26.8±22.6days in LVHs vs. 23.3±21.5days in MVHs vs. 19.7±17.2days in HVHs, P<0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P<0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725). There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.

Emergency ERCP and biliary drainage for acute cholangitis

【目的】急性胆管炎初期治療における内視鏡的胆管ドレナージは診療ガイドラインにて推奨度Aであるが，その方法は各施設の方針に委ねられている。今回，緊急ERCPを施行した急性胆管炎例を検討し標準的ドレナージ法に適した方法につき考察した。【対象】2005年1月より2008年5月の間に緊急ERCPを施行した急性胆管炎56例を対象に，背景疾患，ドレナージ方法と合併症，転帰などにつき検討した。【成績】平均年齢70.7歳で，男女比27 : 29。疾患内訳は総胆管結石初回治療例が34例，悪性疾患初回例が4例，総胆管結石治療後例が3例，ステント留置後の症例が13例，その他（慢性膵炎，PSC）2例であった。重症度は重症9例，中等症43例，軽症4例であった。71.4％に脳・心血管系はじめ併存疾患があり，32.1％が抗凝固・抗血小板治療薬投与中であった。75％が検査時間枠外の処置で，ドレナージ法は96.4％でENBDを選択した（うち87％は乳頭処置をせず）。術後合併症としてENBD自己抜去は2例であった。血液培養陽性30％対し胆汁培養は96.1％で陽性で，84.3％で複数菌が検出された。92.6％でENBDより造影を施行し病巣評価に利用した。【結語】急性胆管炎に対する緊急ERCP，ENBD留置は比較的安全かつ起因菌同定，病巣評価の面からも有用性が高く，緊急時の対応として標準的なものになり得ると思われた。

Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines

Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment, and their condition has not improved. Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous transhepatic, and open methods. The clinical value of both endoscopic and percutaneous transhepatic drainage is well known. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization; therefore, this approach is advocated whenever it is applicable. In endoscopic drainage, either endoscopic nasobiliary drainage (ENBD) or tube stent placement can be used. There is no significant difference in the success rate, effectiveness, and morbidity between the two procedures. The decision to perform endoscopic sphincterotomy (EST) is made based on the patient’s condition and the number and diameter of common bile duct stones. Open drainage, on the other hand, should be applied only in patients for whom endoscopic or percutaneous transhepatic drainage is contraindicated or has not been successfully performed. Cholecystectomy is recommended in patients with gallbladder stones, following the resolution of acute cholangitis with medical treatment, unless the patient has poor operative risk factors or declines surgery.

Endoscopic Emergency Biliary Drainage for Acute Cholangitis with Choledocholithiasis

Endoscopic Emergency Biliary Drainage for Acute Cholangitis with Choledocholithiasis

Experience with percutaneous transhepatic fiberoptic choledochoscopy for retained stones in the biliary tract. Report on 15 patients.

Residual choledochal stones in 11 patients and stones in the intrahepatic bile ducts in 5 patients were successfully removed by the use of the fiberoptic choledochoscope (FCH-6T), introduced percutaneously into the intrahepatic biliary tract. The reasons for the use of percutaneous transhepatic extraction were: (1) unsuccessful endoscopic papillotomy; (2) unsuccessful choledochoscopic removal via the T-tube tract; (3) high surgical risk; (4) the presence of percutaneous transhepatic biliary drainage for acute cholangitis and acute pancreatitis. All stones were extracted through the liver or the papilla of Vater after crushing them. All minor complications such as pain, vomiting, or fever resolved without further therapy. Percutaneous transhepatic choledochoscopy proved safe and effective for the removal of retained choledochal stones and was essential for the treatment of stones in the intrahepatic bile ducts.