Biliary Symptoms Research Articles

S2604 Acute Severe Cholestatic Hepatitis B Infection in an Immune-Competent Patient

INTRODUCTION: Acute severe cholestatic hepatitis B is uncommon and usually reported in organ transplant recipients. We report a unique case of acute HBV infection with severe cholestasis in an immune-competent patient whose symptoms were initially felt to be secondary to complications from choledocholithiasis. CASE DESCRIPTION/METHODS: A 67-year-old female presented with right upper quadrant (RUQ) pain, vomiting, fatigue & jaundice for 2 weeks. She had a new sexual partner with unknown hepatitis status. The patient had no history of alcohol, drug use or new medications. RUQ tenderness & scleral icterus were noted on exam. Labs showed AST-629u/l (Normal[N]: 10–40 u/l), ALT-497u/l (N: 12–78 u/l), ALP-294u/l (N: 33–138 u/l), T. Bili-8.4mg/dl (N: 0.0–1.5 mg/dl), D. Bili-7.5mg/dl (N: 0.0 −1.5mg/dl), INR-1. On ultrasound of the abdomen cholelithiasis with gall bladder wall thickening with normal biliary ducts was noted. Endoscopic ultrasound revealed a 2.5 mm filling defect without shadowing in distal common bile duct (CBD) & Endoscopic retrograde pancreatic duodenoscopy showed a small filling defect in mid CBD and a distal CBD stricture about 1–2 cm in length. Biopsy of CBD stricture showed inflammation. A plastic biliary stent was deployed with good drainage. Her liver tests did not improve, and additional investigations performed were positive for Hepatitis B surface antigen (HbsAg), core antibody Total (Anti HBc Total) & core IgM, Hepatitis e antigen (HBeAg). She was negative for Hepatitis B e antibody (HBeAb) and Hepatitis B surface antibody (HBsAb). HBV PCR was 765,000,000 IU/ml. She was discharged with a follow up scheduled in liver clinic, but was readmitted 2 weeks later with worsening fatigue & liver tests. A liver biopsy showed active hepatitis without evidence of bridging fibrosis or cirrhosis & positive HBV staining. Anti-viral therapy with Tenofovir was initiated with improvement in symptoms. DISCUSSION: Although several case reports describe severe cholestasis with HBV post-liver transplantation, it has rarely been described in immunocompetent patients. Our patient's presentation was initially concerning for biliary obstruction. Despite biliary drainage patient's symptoms worsened, & further investigations revealed acute HBV infection with high replication which was confirmed by biopsy. Prompt therapy with antivirals improved the clinical course. Given these findings one should have high index of suspicion to evaluate for HBV infection in unusual presentation with cholestasis.Figure 1.: Immunohistochemical stain highlights Hepatitis B surface antigen within the cytoplasm of hepatocytes (200X magnification).Figure 2.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (100x magnification).Figure 3.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (200 X magnification).

Sonographically determined clues to the symptomatic or silent cholelithiasis.

To determine an association between sonographically determined contractility with the symptomatic or silent nature of gallstone. Designing: Comparative, cross-sectional study. Radiology Department, Dow University of Health Sciences (DUHS) and Civil Hospital, Karachi (CHK), from April 2004 to March 2005. Adult gallstone patients without (group I) and with biliary symptoms (group II) were compared with age and gender-matched controls. Demographic data, body mass index, risk factors, size, number and mobility of gallstone, gallbladder wall thickness (GBWT), volume and Ejection Fraction (EF) were determined on ultrasound before and after a standardized fatty meal (BFM and AFM). Demographic data, risk factors and gallstone characteristics were analyzed by Pearson Chi-square test and the gallbladder characteristics were analyzed by One-way ANOVA and Post Hoc tests by multiple comparisons on SPSS 11 with significance p=0.05. The gallbladder contractility as measured by changes in wall thickness and volume changes BFM and AFM, and ejection fraction was similar in controls and asymptomatic cholelithiasis groups and significantly reduced in symptomatic patients (p < .001). Multiparity (p=0.002), female gender (p=0.018), age less than 50 years (0.05), impacted calculi (p=0.001), multiple calculi (< .001) and calculi 5mm (p < 0.001) were associated with pain. A sluggishly emptying gallbladder was more significantly associated with symptomatic cholelithiasis compared to controls and asymptomatic cholelithiasis state in this series. Consideration of age, gender, impaction of calculi, number and size of calculi is important in causing symptom state and management options.

Diagnostic Accuracy of Ultrasound in Correlation to Alkaline Phosphatase Levels in Patients with Biliary Obstructions

Abdominal Ultrasonography (USG) is an appropriate initial screening method for detection of biliary tract disease the consultants sometimes encounter patients who only have findings of dilatation of the Common Bile Duct (CBD) on US without specic biliary symptoms or jaundice.

Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal

BackgroundRecent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP.MethodsWe retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP.ResultsThe rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19–9.88; P = 0.02).ConclusionsWhen removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.

Biliary hyperkinesia: an indication for cholecystectomy?

The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2weeks and 10-16months after surgeries. Over 7years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Low phospholipid-associated cholelithiasis syndrome: A rare cause of acute pancreatitis that should not be neglected.

BACKGROUNDLow phospholipid-associated cholelithiasis (LPAC) syndrome is a very particular form of biliary lithiasis with no excess of cholesterol secretion into bile, but a decrease in phosphatidylcholine secretion, which is responsible for stones forming not only in the gallbladder, but also in the liver. LPAC syndrome may be underreported due to a lack of testing resulting from insufficient awareness among clinicians.AIMTo describe the clinical and radiological characteristics of patients with LPAC syndrome to better identify and diagnose the disease.METHODSWe prospectively evaluated all patients aged over 18 years old who were consulted or hospitalized in two hospitals in Paris, France (Bichat University Hospital and Croix-Saint-Simon Hospital) between January 1, 2017 and August 31, 2018. All patients whose profiles led to a clinical suspicion of LPAC syndrome underwent a liver ultrasound examination performed by an experienced radiologist to confirm the diagnosis of LPAC syndrome. Twenty-four patients were selected. Data about the patients’ general characteristics, their medical history, their symptoms, and their blood tests results were collected during both their initial hospitalization and follow-up. Cytolysis and cholestasis were expressed compared to the normal values (N) of serum aspartate and alanine transaminase activities, and to the normal value of alkaline phosphatase level, respectively. The subjects were systematically reevaluated and asked about their symptoms 6 mo after inclusion in the study through an in-person medical appointment or phone call. Genetic testing was not performed systematically, but according to the decision of each physician.RESULTSMost patients were young (median age of 37 years), male (58%), and not overweight (median body mass index was 24). Many had a personal history of acute pancreatitis (54%) or cholecystectomy (42%), and a family history of gallstones in first-degree relatives (30%). LPAC syndrome was identified primarily in patients with recurring biliary pain (88%) or after a new episode of acute pancreatitis (38%). When present, cytolysis and cholestasis were not severe (2.8N and 1.7N, respectively) and disappeared quickly. Interestingly, four patients from the same family were diagnosed with LPAC syndrome. At ultrasound examination, the most frequent findings in intrahepatic bile ducts were comet-tail artifacts (96%), microlithiasis (83%), and acoustic shadows (71%). Computed tomography scans and magnetic resonance imaging were performed on 15 and three patients, respectively, but microlithiasis was not detected. Complications of LPAC syndrome required hospitalizing 18 patients (75%) in a conventional care unit for a mean duration of 6.8 d. None of them died. Treatment with ursodeoxycholic acid (UDCA) was effective and well-tolerated in almost all patients (94%) with a rapid onset of action (3.4 wk). Twelve patients’ (67%) adherence to UDCA treatment was considered “good.” Five patients (36%) underwent cholecystectomy (three of them were treated both by UDCA and cholecystectomy). Despite UDCA efficacy, biliary pain recurred in five patients (28%), three of whom adhered well to treatment guidelines.CONCLUSIONLPAC syndrome is easy to diagnose and treat; therefore, it should no longer be overlooked. To increase its detection rate, all patients who experience recurrent biliary symptoms following an episode of acute pancreatitis should undergo an ultrasound examination performed by a radiologist with knowledge of the disease.

Gastrointestinal symptoms in acromegaly: A case control study.

BACKGROUNDAcromegaly is a chronic disease caused by a pituitary somatotroph adenoma resulting in excess secretion of growth hormone, which leads to excess secretion of Insulin like growth factor 1 from the liver, causing abnormal soft tissue growth. There is increasing awareness that diseases affecting connective tissue are associated with an increase in functional gastrointestinal symptoms. Data was collected from patients with a confirmed diagnosis of acromegaly to evaluate the intensity, variety and impact of abdominal symptoms in comparison with a control group who were healthy participants recruited from the local fracture clinic.AIMTo evaluate the frequency type and burden of abdominal symptoms in acromegaly in comparison with a control group.METHODSMedical documentation of patients with a diagnosis of acromegaly treated in one tertiary medical centre between 2010 and 2017 has been analysed. Data was collected from patients with confirmed acromegaly, using the Short Form Health Survey (SF36) and Rome IV Diagnostic questionnaire for Functional Gastrointestinal Disorders in Adults (R4DQ) and compared to a sex- and age-matched control group, to assess the burden of abdominal symptoms. Microsoft Excel and IBM SPSS v 25 were used for data analysis.RESULTSFifty patients with acromegaly (24 male and 26 females; age range 23-64 years, mean 43) and 200 controls (96 male and 104 females; age range 18-84, mean 42.4) were recruited. 92% (46 out of 50) of patients with acromegaly reported abdominal symptoms and 78% (39 out of 50) had at least one functional gastrointestinal disorder according to the Rome IV diagnostic criteria, compared to 16% of controls (OR > 1, P < 0.0001). The most commonly reported symptom was constipation (69% acromegaly vs 21% of controls OR > 1, P < 0.0001, 95%CI: 4.4–15.8). 34 out of 50 (68%) respondents met the criteria for functional constipation according to Rome IV. Upper gastrointestinal disorders were also more prevalent in the acromegaly group. There was no statistically significant difference in the prevalence of biliary and anorectal symptoms between the two groups. Patients in acromegaly group scored lower on the mean scores of the eight parameters of SF36 Quality of Life questionnaire (mean scores 60.04 vs 71.23, 95%CI: -13.6829 to -8.6971, OR > 1, P < 0.001) as compared to the control group.CONCLUSIONUpper and lower functional gastrointestinal tract disorders (defined by Rome IV diagnostic criteria) are significantly more prevalent in patients with acromegaly compared with healthy age and sex matched controls in our study. Functional constipation is the most commonly reported problem. Poorer quality of life may in part be attributable to the increased prevalence of abdominal symptoms.

Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review.

Patients with typical biliary pain, no gallstones on ultrasound and low gallbladder ejection fraction (GBEF) on cholescintigraphy (gallbladder dyskinesia) may be considered for a laparoscopic cholecystectomy. However, some studies have suggested that symptoms alone are an adequate indication for laparoscopic cholecystectomy. The aim was to determine the role of cholescintigraphy in predicting outcomes of cholecystectomy in patients with typical and atypical biliary symptoms and normal biliary ultrasound. Meta-analysis using Preferred Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines of published literature using several electronic databases. Twenty-four articles were selected with a total of 1710 patients. The majority (n = 1633, 94.4%) of patients had typical biliary symptoms. A total of 1047 patients with typical symptoms and a reduced GBEF had a cholecystectomy with 852 (81.4%) having complete resolution of symptoms. A total of 148 with typical symptoms and normal GBEF had a cholecystectomy with 103 (69.5%) having complete resolution, which was significantly less than those with a reduced GBEF (odds ratio 1.65, confidence interval 1.08-2.05, P = 0.01). Forty-five patients with atypical symptoms and a reduced GBEF had a cholecystectomy with 31 (68.9%) having complete resolution of symptoms, which is significantly lower than those with typical symptoms (odds ratio 1.97, confidence interval 0.95-3.90, P = 0.05). Cholescintigraphy improved the predication of outcome of cholecystectomy in biliary dyskinesia by 10%. However, the presence of typical symptoms does predict an effective response in 70% of patients. Atypical symptoms predict a poorer response.

The usage of prior upper gastrointestinal endoscopy among symptomatic patients undergoing cholecystectomy

Background: Cholelithiasis is one of the most common problems encountered in surgery. It is an immense challenge to discriminate between signs and symptoms due to gastrointestinal lesions and gallstones diseases. The objective of this study was to evaluate the usage of pre-operative upper gastrointestinal endoscopy (UGE) as a routine in treating symptomatic gallstone patients.Methods: This prospective hospital based observational study was conducted in the Department of General Surgery at Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar from January 2018 to June 2019. 60 symptomatic gallstone patients were selected for cholecystectomy and preoperative upper gastrointestinal (GI) endoscopy evaluation was done for any associated upper gastrointestinal problems.Results: Out of the total patients, females constituted 85% of overall study patients and majority of the patients presented with atypical biliary colic symptoms (55%, group 2) whereas 45% presented with typical biliary colic symptoms (group 1) (p value=0.009). Relief rate was highest in group 1 with abnormal UGE than with group 2.Conclusions: The routine use of upper GI endoscopy in patients with symptomatic cholelithiasis prior to cholecystectomy will help reduce post-operative persistence of symptoms and thus, it is a useful investigation in the overall treatment of gallstone diseases.

Bouveret’s syndrome and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

Serum Carbohydrate Antigen 199 as a Biomarker for Evaluating Patients with Choledocholithiasis.

Aims Choledocholithiasis is a common and yet potentially debilitating disease of the biliary tract. While certain patients with this disease remain largely asymptomatic or experience mild discomfort, in several cases, patient can suffer biliary inflammation and other serious symptoms. Previous studies have detected elevated serum levels of carbohydrate antigen 199 in patients with choledocholithiasis. We wanted to know whether serum CA199 level in patients with choledocholithiasis is related to the level of inflammation in patients. Methods In the present study, we separated a cohort of 135 choledocholithiasis patients into two groups based on their white blood cell counts, which were either 3.5 − 9.5 × 109/L or ≥9.5 × 109/L. We also divided patients into two groups according to CPR < 10 mg/L and CRP ≥ 10 mg/L. At the same time, the correlation between CA199 and CRP level was analyzed. Results We then used a Rank-sum test to compare serum carbohydrate 199 levels between these groups, revealing significantly higher levels of this antigen in patients with a white cell count ≥9.5 × 109/L (Z = −3.584, P < 0.01). The two groups were grouped by CRP, and the CA199 level was compared. The difference between the two groups was statistically significant (P < 0.01). The correlation analysis between CA199 and CRP showed an obvious correlation (r = 0.574). Conclusion This suggests that in patients with choledocholithiasis, higher circulating carbohydrate antigen 199 levels may correspond to a higher degree of inflammation.

Prevalence and risk factors of gallstone disease in patients undergoing ultrasonography at Mulago hospital, Uganda.

Gallstone disease (GSD) is the most prevalent medical condition in the pancreatobiliary system. The burden of GSD and its complications are major public health issues globally. It is a common cause of surgical intervention, contributing substantially to health care costs. Most patients are asymptomatic, however 20% become symptomatic after 10 years. Its prevalence differs among populations and remains unknown in Uganda. To determine the prevalence and risk factors of GSD in patients undergoing abdominal ultrasonography at Mulago hospital, Uganda. This was a cross-sectional study at the Department of Radiology in Mulago hospital. Convenient sampling was used to recruit individuals having an abdominal ultrasound scan. Questionnaires were used to assess risk factors, and an abdominal exam was performed for individuals with gallstones to assess symptomatology. The prevalence of GSD was 22%. Statistically significant factors associated with GSD were a history of hormonal contraceptive use OR 3.2 (1.88-5.41) and a history of previous biliary symptoms OR 2.9 (1.68-4.91). Ninety-four percent of individuals with gallstones had epigastric/right upper quadrant pain. The prevalence of GSD is high in Mulago hospital; use of hormonal contraceptives and a previous history of biliary symptoms were significant risk factors for GSD in this study. Majority of patients with GSD were symptomatic with epigastric pain as the cardinal symptom. We recommend a countrywide screening program using abdominal ultrasonography to determine the prevalence of GSD in the general population. There is need to study further the risk of hormonal contraceptive use and GSD. Women on these contraceptives should be informed of the potential risk, and offered alternative options where feasible.

Gallstone disease - interdisciplinary treatment

Gallstones develop in the gallbladder or the bile ducts. According to their chemical composition, gallstones can be divided into cholesterol stones, which are common, and the rare bile pigment stones. Altogether, up to 20 % of all adults develop gallstones and more than 20 % of them symptoms or complications. Female sex, age, pregnancy, physical inactivity, obesity, overnutrition and genetic factors such as ABCB4 deficiency of the hepatic lecithin transporter are kown risk factors for gallstone formation. In about one half of all patients biliary symptoms precede the three common and potentially life-threatening complications (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge about the genetics and pathophysiology of gallstones has improved, current treatment algorithms are predominantly invasive (ERC and surgery). Thus, better strategies are needed to prevent the formation of gallstones in general.

Risk Factors for Cholecystectomy After Laparoscopic Roux-En-Y Gastric Bypass

BackgroundPatients who have undergone bariatric surgery are at risk for subsequent cholecystectomy. We aimed to identify risk factors for cholecystectomy after laparoscopic Roux-en-Y gastric bypass (LRYGB).MethodsWe conducted a retrospective case-control study of patients who underwent LRYGB between 2013 and 2015. Cases underwent cholecystectomy because of biliary symptoms after LRYGB. For each case, two controls were selected without subsequent cholecystectomy. Logistic regression analyses were used to identify risk factors.ResultsBetween 2013 and 2015, 1780 primary LRYGBs were performed. We identified 233 (13.1%) cases who had undergone cholecystectomy after a median (IQR) of 12 (8–17) months, and 466 controls. Female gender (OR (95% CI) 1.83 (1.06–3.17)), Caucasian ethnicity (OR (95% CI) 1.82 (1.10–3.02)), higher percent total weight loss (%TWL) at 12 months (OR (95% CI) 1.06 (1.04–1.09)), and preoperative pain syndrome (OR (95% CI) 2.72 (1.43–5.18)) were significantly associated with an increased risk for cholecystectomy. Older age (OR (95% CI) 0.98 (0.96–0.99)) and preoperative statin use were associated with a reduced risk (OR (95% CI) 0.56 (0.31–1.00)). A dose-effect relationship was found between the intensity of preoperative statin and risk for cholecystectomy.ConclusionsIn our study, higher %TWL and preoperative pain syndrome were associated with an increased risk for cholecystectomy besides the traditional risk factors female gender and Caucasian ethnicity. These factors can be used to identify high-risk patients, who might benefit from preventive measures. Whether statins can protect bariatric patients from developing gallstones should be investigated prospectively.

109. Clinical Characteristics and Outcomes of Staphylococcus aureus Bacteremia From a Biliary Source

Background Staphylococcus aureus can cause various types of infection, but involvement of biliary tract is rare. There were only few case reports and no clinical studies. We assessed the clinical characteristics and outcomes of S. aureus bacteremia from a biliary source (biliary SAB) in a large cohort of SAB patients and compared the cases with those of catheter-related SAB.MethodsWe performed a matched case–control study within a prospective observational cohort of patients with SAB at a 2,700-bed tertiary hospital. All adult patients with SAB were observed for 12 weeks from July 2008 to July 2018. Biliary SAB was defined as the case of S.aureus isolated from blood culture with appropriate clinical biliary infection symptoms (fever, abdominal pain, or jaundice) and signs (abdominal tenderness or liver enzyme elevation with obstructive pattern). Biliary SAB cases were matched 1:3 to control patients with catheter-related SAB based on age, gender, ward, and case year.ResultsA total of 1,818 patients with SAB were enrolled in the entire cohort, and 42 (2%) were biliary SAB. Among patients with biliary SAB, 32 (76%) had solid tumor involving pancreaticobiliary tract or liver, 30 (71%) had biliary drainage stent, 14 (33%) were biliary procedure-related infection, and 24 (57%) had recent broad-spectrum antibiotics exposure (Table 1). When biliary SAB patients were compared with 126 patients with catheter-related SAB, they were significantly more likely to have community-onset SAB, solid tumor, and lower APACHE II score; and less likely to have metastatic infection (P = 0.03) (Table 2). Biliary SAB, solid tumor, and a high Charlson comorbidity index were associated with 12-week mortality. In multivariate analysis, biliary SAB (aOR, 5.5; 95% CI, 2.47–12.25) and a high Charlson comorbidity index (aOR, 1.32; 95% CI, 1.12–1.54) were independent risk factors for 12-week mortality.ConclusionBiliary SAB was relatively rare and developed mainly in pancreaticobiliary cancer patients and in recent broad-spectrum antibiotic users. High mortality was probably attributable to underlying cancers. When biliary tract infection caused by S. aureus is clinically suspected, early aggressive treatment for SAB should be considered. Disclosures All authors: No reported disclosures.

Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations.

BackgroundEarly laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra‐operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a ‘complicated’ LC.MethodsRetrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra‐operative findings (grades 1–4). Pre‐operative predictors for a ‘complicated’ LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut‐off and accuracy of the model were assessed using a receiver operating characteristic curve.ResultsA total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a ‘complicated’ LC. A prediction model for a ’complicated’ LC (0–4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C‐reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre‐operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively.ConclusionEarly LC may be ‘complicated’ in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely ‘complicated’ LC in patients with acute biliary presentations.

2168 Type II Choledochal Cyst With Obstructive Jaundice and Chronic Pancreatitis: A Case Report

INTRODUCTION: Choledochal cysts are a rare congenital cystic dilation of the biliary tract and occur commonly in female infants and young children. Although rare in Western countries, choledochal cysts are more common in East Asian countries with Type II cysts accounting for only 2% of reported cases. We present an interesting case of a Type II choledochal cyst in a patient with chronic pancreatitis. CASE DESCRIPTION/METHODS: A 56 year old male presented with abdominal pain associated with nausea and non-bloody emesis. He also had reduced appetite, dark urine, and a 10 pound weight loss over several months. Physical examination revealed scleral icterus and epigastric abdominal tenderness. Laboratory investigations revealed mild leukocytosis (11.1), elevated total bilirubin (8.6), aspartate aminotransferase (77), alanine aminotransferase (128), and alkaline phosphatase (556). A CT with intravenous contrast (Figure 1) demonstrated coarse calcifications within the pancreas, a large cystic lesion within the head of the pancreas with marked pancreatic ductal dilation, atrophy, and intraductal calcifications. Gallbladder distension with sludge and upstream biliary dilatation was also noted. Endosonographic images (Figure 2) revealed an anechoic cystic lesion in the head of the pancreas with compression of the common bile duct (CBD). Fine needle aspiration was performed with aspirated fluid highly suggestive of bile. A cholangiogram confirmed the presence of an intrapancreatic cystic cavity in direct communication with the distal CBD in a diverticular configuration suggestive of a Type II choledochal cyst with narrowing of the adjacent CBD. A pancreatic sphincterotomy followed by pancreas stone lithotripsy and stone extraction was performed. A biliary stent was placed into the CBD. The patient tolerated the procedure well and was scheduled for multidisciplinary discussion pending brush cytology. DISCUSSION: Choledochal cysts are congenital anomalies which results in cystic dilation of the biliary tree. Adults are more likely to present with biliary or pancreatic symptoms whereas children present with an abdominal mass and jaundice. Malignancy is associated with Type I and IV cysts while Types II, III, and V cysts have minimal neoplastic risk. Treatment is based on the cyst type. Diverticulectomy of Type II choledochal cyst followed by primary CBD closure at the diverticulum neck is usually sufficient. A multidisciplinary approach may be warranted based on patient clinical status and co-morbidities.

116 The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single Center Study

INTRODUCTION: Acute cholangitis is a serious inflammatory and infectious disease of the bile duct that requires prompt treatment. Choledocholithiasis is the main cause of acute cholangitis and requires biliary clearance using endoscopic retrograde cholangiopancreatography (ERCP). Following endoscopic clearance of the bile duct in patients with acute cholangitis, laparoscopic cholecystectomy (LC) is recommended for patients with gallstones. However, the timing of LC following acute cholangitis is still debatable. The aim of our study was to assess the impact of performing LC during admission following ERCP on the 30-day readmission rate. METHODS: A retrospective cohort study of acute cholangitis patients between April 2013 and May 2018. Patients were 18 years or older with a definite diagnosis of acute cholangitis based on Tokyo guidelines 2018. We only included acute cholangitis patients who underwent ERCP with complete clearance of the bile duct. Patients with malignant biliary strictures, a history of cholecystectomy, acute cholecystitis, intrahepatic ductal stones, primary sclerosing cholangitis, or cirrhosis were excluded. The primary outcome of the study was the 30-day readmission rate. RESULTS: A total of 95 patients with acute cholangitis were included in the study (Tables 1 and 2). Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the LC group compared to the ERCP alone group (2.8% vs. 26.6%, P 0.003). There were no reported deaths in the LC group within 30 and 90 days of discharge, however the mortality rates in the ERCP alone group were 5.0% and 6.6%, respectively. In a multivariate analysis, performing LC during admission was an independent factor for 30-day readmission after adjusting for all other factors, where patients who underwent LC during admission had 90% less chance of readmission within 30 days (OR 0.1, 95% CI (0.01–0.86), P 0.03) (Table 2). CONCLUSION: Performing laparoscopic cholecystectomy during admission for acute cholangitis patients following endoscopic clearance of the bile duct was associated with a significant decrease (Absolute Reduction Rate 23.8%) in 30-day readmission rate. Several studies reported the safety of early LC in acute cholangitis patients as well as a decrease in the recurrence of biliary symptoms. Therefore, performing LC during admission should be recommended for acute cholangitis patients following endoscopic clearance of the bile duct.

Abnormal pathology in cholecystectomy patients with normal preoperative studies

Background: Right upper quadrant abdominal pain is a common complaint often associated with gallbladder disease. However, there may be a subset of patients with true gallbladder pathology who do not have definitively positive preoperative studies. We seek to demonstrate the outcomes in this patient subpopulation. Methods: A retrospective chart review of all patients undergoing laparoscopic cholecystectomy for clinical history of biliary symptoms with classically “normal” ultrasound and HIDA scan were included. Patients were polled regarding their symptoms preoperatively and postoperatively at time of surgical follow-up. Results: Thirty-three patients underwent minimally invasive cholecystectomy during the study period with normal preoperative evaluations despite clinical symptoms consistent with biliary pathology. Of these 33 patients, all reported resolution or significant improvement in symptoms post-operatively. Conclusions: Currently available methods for the preoperative evaluation of gallbladder pathology may underdiagnose the true incidence of gallbladder disease, and cholecystectomy should be considered in these patients with a clinically significant history despite normal studies.

Treatment and survival rates of stage IV pancreatic cancer at VA hospitals: a nation-wide study.

Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in Veterans' Affairs' (VA) hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons' (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied. Nationwide data from the National Veterans Affairs Cancer Cube Registry was analyzed. In total, 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website. MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality was men (97.44%). The above 70 years age group and the 60-70 years age group were the most common ages at diagnosis with 39.39% and 38.02% respectively. The proportion of early-onset pancreatic cancer (EOPC) was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.33% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC-accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC-accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of 8.89% and 8.57%, respectively. Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.