Mild Acute Cholangitis Research Articles

Digital cholangioscopy-assisted, direct visualization-guided, radiation-free, endoscopic retrograde intervention for cholelithiasis: technical feasibility, efficacy, and safety.

Nonradiation, digital cholangioscope (DCS)-assisted endoscopic intervention for cholelithiasis has not been widely performed. For this study, we aimed to report the feasibility, efficacy, and safety of an established DCS-guided lithotomy procedure. Data relating to biliary exploration, stone clearance, adverse events, and follow-up were obtained from 289 patients. The choledocholithiasis-related outcomes via the DCS-guided procedure were subsequently compared to those via conventional endoscopic retrograde cholangiopancreatography (ERCP). Biliary access was achieved in 285 patients. The technical success rate for the exploration of the common bile duct, the cystic stump, the hilar ducts, and secondary radicals was 100%. Moreover, the success rates were 98.4%, 61.7%, and 20.7%, for the exploration of the cystic duct, complete cystic duct, and gallbladder, respectively. Suspicious or confirmed suppurative cholecystitis, cholesterol polyps, and hyperplastic polyps were detected in 42, 23, and 5 patients, respectively. Stone clearance was achieved in one session in 285 (100%), 11 (100%), 13 (100%), 7 (100%), 6 (100%), and 3 (14.3%) patients with choledocholithiasis and hepatolithiasis, cystic duct stump stones, nondiffuse located intrahepatic lithiasis, a single cystic duct stone, a single gallbladder stone, and diffuse located intrahepatic lithiasis, respectively. Complete stone clearance for diffuse intrahepatic lithiasis was achieved in 19 (90.5%) patients, and fractioned re-lithotomy was performed in 16 (76.2%) patients. One patient developed mild acute cholangitis, and 12 developed mild pancreatitis. Stones recurred in one patient. Compared with conventional ERCP, DCS-guided lithotomy has the advantages of clearing difficult-to-treat choledocholithiasis and revealing concomitant biliary lesions, and this technique has fewer complications and a decreased risk of stone recurrence. The technical profile, efficacy, and safety of nonradiation-guided and DCS-guided lithotomy are shown in this study. We provide a feasible modality for the endoscopic removal of cholelithiasis.

Biliary Drainage For Sepsis Control In Acute Cholangitis: A Case Report

Acute cholangitis leading to sepsis is a common occurrence, especially in populations with a highprevalence of gallstones. Unfortunately, the mortality rate related to this issue is high. Recently,we had a case involving an elderly woman who initially had mild acute cholangitis, but it progressedinto a severe case. Respiratory and hematological issues developed, along with worsening septicparameters and liver functions. As a result, she was intubated, ventilated, and monitored in theintensive care unit (ICU). Urgent ERCP failed, but PTBD and percutaneous cholecystostomy wereinserted to aid in biliary decompression and sepsis control. Currently, she is recovering fromsepsis and plans for early ERCP and cholangiogram before definitive surgical intervention. Tohandle obstructed biliary sepsis, early biliary drainage is crucial for urgent biliary decompressionand sepsis control, alongside fluid resuscitation, intravenous antibiotics, and intensive care.

The Predictive Value of Different Laboratory Indicators Based on the 2018 Tokyo Guidelines for the Severity of Acute Cholangitis

BackgroundThis study evaluated the predictive value of different laboratory indicators for the severity of acute cholangitis (AC) according to the 2018 Tokyo Guidelines. ObjectivesWe enrolled consecutive patients with a diagnosis of AC from June 2016 to May 2021. Serum procalcitonin (PCT) and C-reactive protein (CRP) levels, white blood cell counts, the neutrophil–lymphocyte ratio, and the platelet–lymphocyte ratio (PLR) were compared according to the severity of AC. ResultsIn total, 293 patients were enrolled in this study (mild, n = 172; moderate, n = 68; severe, n = 53). In receiver operating characteristic analyses, CRP was the best biomarker for differentiating mild and moderate AC (area under the curve [AUC] 0.66, 95% confidence interval [CI] 0.58–0.74). PCT was the best biomarker for differentiating mild and severe AC (AUC 0.80, 95% CI 0.74–0.86). Blood culture was performed in 117 patients (39.93%), 53 of whom (45.30%) had positive results. Regarding blood culture positivity, PLR was most predictive (AUC 0.85, 95% CI 0.78–0.92). ConclusionsPCT can be used as a reliable predictor of severe AC. CRP was most predictive of moderate AC, whereas PLR was most predictive of blood culture positivity.

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

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

Evaluation of prognosis of acute colangitis patients via hematological parameters

Early differentiation of cases with severe acute cholangitis is important for optimal treatment. In this study, it was aimed to elucidate the prognosis with complete blood count parameters among patients with acute cholangitis. Clinical and laboratory findings of 200 patients with acute cholangitis at Ankara City Hospital between February 2019 and October 2019 were retrospectively analyzed. Neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, red cell distribution width and mean platelet volume levels were recorded from blood analysis at the time of admission. According to Tokyo guidelines, patients were divided into 3 groups as mild, moderate and severe acute cholangitis. In order to evaluate the prognosis, the length of hospital stay, the status of hospitalization in the medical intensive care unit and blood culture growth were investigated with hematological parameters. Of the 200 patients, 109 (54.5%) were male and 91 (45.5%) were female. According to Tokyo criteria, 17 patients’ status was evaluated as severe, 70 as moderate and 113 as mild acute cholangitis. The area under the receiver operating characteristics curve for neutrophil-lymphocyte ratio measurements was statistically significant in distinguishing the mild vs moderate disease (AUC=0.694; 95% Confidence Interval (CI):0.586-0.802 and p=0.008), with a diagnostic accuracy rate of 59.5%. The diagnostic accuracy rate of red cell distribution width (AUC=0.603; 95% CI: 0.523-0.683 and p=0.013) was 61.5% and the diagnostic accuracy rate of mean platelet volume (AUC=0.582 95% CI: 0.502-0.662 and p=0.047) was 57.5% achieving a statistical significance. Neutrophil-lymphocyte ratio, red cell distribution width and mean platelet volume analysis is routinely obtained from complete blood count almost in every patient. These are inexpensive and easily accessible diagnostic markers and thus, might be useful in the differentiation of mild and severe acute cholangitis patients and their prognosis.

Validation of Tokyo guidelines 2018 for safety and mortality benefit from urgent ERCP in acute cholangitis across different age groups.

The 2018 Tokyo Guidelines (TG18) recommend urgent endoscopic biliary drainage based on acute cholangitis (AC) severity. Therefore, we evaluated the safety and mortality benefits of urgent endoscopic retrograde cholangiopancreatography (ERCP) in different age groups. Using International Classification of Diseases-10 (ICD-10) codes, we sampled adult AC patients from National Inpatient Sample. TG18 definition of cholangitis severity was used to identify patients with severe and nonsevere (mild or moderate) AC. Age categories were 18-64, 65-79, and 80 and above. Multivariate linear or logistic regression was used as appropriate. We used Stata, version 14.2, to perform analyses considering two-sided p< .05 as statistically significant. Among 137 100 patients, there were 93 365 (68.09%) patients with nonsevere cholangitis and 43 735 (31.91%) patients with severe cholangitis. Urgent ERCP (within 24 h) resulted in decreased mortality in all age groups for both severe and nonsevere AC. Post-sphincterotomy bleeding was more common in patients ≥80 years of age, whereas post-ERCP acute cholecystitis was more common in patients 65-79 years. The rates of post-ERCP pancreatitis, bile duct perforation, and duodenal perforation did not differ among the age groups. In addition, there were no differences in the rate of sedation-related complications between different age groups who underwent urgent ERCP. This study demonstrates the mortality benefit from urgent ERCP for AC in different age groups and describes the safety of performing urgent ERCP in patients of various ages. Therefore, we recommend that urgent ERCP be performed according to the TG18 guidelines regardless of age.

Lipocalin2 as a useful biomarker for risk stratification in patients with acute cholangitis: A single-center prospective and observational study

BackgroundLipocalin2 (LCN2) is being increasingly used to diagnose and predict severe bacterial infection. We aimed to evaluate the predictive value of serum lipocalin 2 for severity grading of acute cholangitis (AC) on patient admission. MethodsA total of 108 patients were enrolled in this study. Blood samples were obtained at admission. Receiver operating characteristic (ROC) curves were built to assess the abilities of LCN2 levels to predict moderate/severe (vs. mild) or severe (vs. mild/moderate) AC with traditional markers of inflammation such as white blood cell (WBC) count, C-reactive protein (CRP), procalcitonin (PCT) and neutrophil-to-lymphocyte ratio (NLR). The correlations among the key research indicators were determined using spearman’s test. Multivariate analysis was conducted to identify the risk factors for severe AC. ResultsThe levels of LCN2 on admission increased significantly with the severity of AC. By analysis of ROC curve of biomarkers for differentiating patients with moderate to severe AC (versus mild AC), the AUC for LCN2 (0.925) was significantly greater than that for other inflammatory markers, and the optimal cut-off value of LCN2 was 262.2 ng/mL, with a sensitivity of 90.8% and specificity of 81.4%. In addition, the AUC for LCN2 (0.912) for severe acute cholangitis was also significantly greater than that for other inflammatory markers, and the optimal cut-off value of LCN2 was 325.7 ng/mL. The sensitivity and specificity were 86.1% and 83.3%, respectively. Furthermore, LCN2 the closest relationships were found between LCN2 and PCT (r = 0.8054, P < 0.001) through Spearman’s test. Multivariate analysis showed that LCN2 was the only risk factor predicting severe AC (P < 0.05). ConclusionSerum LCN2 concentration on patient admission could better predict severe acute cholangitis than WBC, CRP, PCT and NLR. Serum LCN2 may become a potential biomarker in the risk stratification of acute cholangitis and in indicating the time of biliary drainage.

Should lactate be added to Tokyo criteria for the evaluation of patients with acute cholangitis?

Tokyo guidelines (TG13/18) are used for the severity assessment of acute cholangitis (AC). Lactate is a clinical marker of tissue hypoxia and disease severity, independent from blood pressure. The aim of this study is to investigate the relationship between blood lactate level and TG13/18 criteria in patients diagnosed with AC. One hundred fifteen patients with AC were included in this retrospective study. Demographic characteristics of the patients and laboratory data were scanned from their hospital medical records. According to TG13/18 guidelines, the patients were divided into 3 groups as mild (grade 1), moderate (grade 2), and severe (grade 3) AC. Sixty three (54.7%) of the patients were grade 1, 37 (32.1%) were grade 2, and 15 (13.0%) were grade 3. It was found that blood lactate level increased significantly from grade 1 to grade 3 (p < 0.001). In logistic regression analysis, white blood cell (WBC) count, total bilirubin and blood lactate levels independently determined the patients to be grade 2 or 3 AC. When the blood lactate cut-off value was taken as 16.5mg/dL, we diagnosed grade 2 or 3 AC with a sensitivity of 78.8% and a specificity of 75.7%. From among lactate, WBC, and C reactive protein, lactate showed the highest value regarding the area under the curve, which is an index for predicting grade III upon ROC analysis. The blood lactate level is associated with the severity of AC. In addition to TG13/18 guidelines, blood lactate level can be a useful biomarker in the severity grading of AC.

Validation of TG07 and TG13/TG18 criteria for acute cholangitis and predictors of in-hospital mortality in patients over 80 years old.

Aim of the studyThis study aims to validate Tokyo guidelines (TG) TG07/TG13/TG18 criteria and identify predictors of in-hospital mortality in acute cholangitis (AC) patients over 80 years old.Material and methodsThis is a retrospective audit of AC patients from January 2009 to December 2016. Demographic, clinical, investigation, management, and mortality data were studied. Multinomial logistic regression analysis with stepwise variable selection identified predictors for in-hospital mortality.ResultsThree hundred and eighty-eight patients were treated for AC. One hundred and sixty-two (41.8%) patients were male. 230 (59.3%) patients had a history of biliary disease, 161 (41.5%) patients had type 2 diabetes mellitus (T2DM), and 98 (25.3%) patients had ischaemic heart disease (IHD). Abdominal pain (n = 226, 58.2%), pyrexia (n = 247, 63.7%), and vomiting (n = 159, 41.0%) were the common presenting symptoms. 191 (49.2%) patients had abdominal tenderness. Positive blood cultures were recorded in patients 158 (40.7%) patients. Escherichia coli was the most commonly identified organism (n = 117, 30.2%). 77 (19.8%), 188 (48.5%) and 123 (31.7%) patients were graded with mild, moderate, and severe AC, respectively. 30-day, 90-day, and in-hospital mortality were 9 (2.3%), 19 (4.9%) and 38 (9.8%), respectively. On multivariate analysis, systolic blood pressure ≤ 100 mmHg (OR = 3.817, 95% CI: 1.365-10.761, p = 0.011), hypoalbuminaemia < 28 gm/l (OR = 6.052, 95% CI: 2.635-13.904, p < 0.001), serum creatinine ≥ 176.8 (OR = 2.787, 95% CI: 1.146-6.778, p = 0.024) and international normalized ratio (INR) > 1.5 (OR = 3.247, 95% CI: 1.234-8.544, p = 0.017) were independent predictors of in-hospital mortality.ConclusionsHypotension, hypoalbuminaemia, elevated creatinine, and elevated INR predict in-hospital mortality in AC patients over 80 years old.

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.

Role of Presepsin for the Assessment of Acute Cholangitis Severity.

Presepsin is a new emerging inflammatory biomarker. The primary purpose of this study was to elucidate the predictive usability of presepsin for severity assessment in patients with acute cholangitis (AC). A total of 119 treatment-naive patients with AC (64 males, 55 females) were enrolled in this study. Patients were classified with Grade I (mild), Grade II (moderate), or Grade III (severe) AC based on severity assessment guidelines. Presepsin concentrations were measured on admission. The median presepsin concentrations were 297 pg/mL (interquartile range (IQR) 234 - 386 pg/mL), 590 pg/mL (IQR 559 - 619 pg/mL), and 857 pg/mL (IQR 740 - 960 pg/mL) in patients with mild, moderate, and severe AC, respectively. Presepsin concentrations were significantly higher in patients with severe AC than in patients with moderate AC (p < 0.01), and in patients with moderate AC than in patients with mild AC (p < 0.01). With the receiver operating characteristic (ROC) analysis, the areas under the curves (AUCs) for presepsin to discriminate patients with moderate and severe AC were 0.935 (95% confidence interval (CI) 0.877 to 0.993, p < 0.001) and 0.942 (95% CI 0.885 to 0.998, p < 0.001), respectively. Compared with other conventional biochemical indicators such as WBC, CRP, and PCT, presepsin may be a useful parameter for the severity assessment of AC.

Eggerthella lenta bacteraemia in a patient with Caroli disease

Introduction: Eggerthella lenta is an obligate anaerobic, non-spore-forming, Gram-positive rod found as a normal commensal of the human intestinal flora, which is capable of reducing digoxin into several metabolites. Disease caused by this micro-organism is unusual, although more frequent than reported. Case presentation: A 74-year-old man presented to the emergency room and was admitted with a mild acute cholangitis syndrome. One anaerobic blood culture became positive after 5 days of incubation. After an additional 5 days, the usual aerobic subcultures were negative, whereas anaerobically incubated Columbia blood agar presented tiny smooth colonies. The isolate was capable of reducing digoxin and was identified as Eggerthella lenta. Adequate antibiotic treatment with meropenem had been started and the patient recovered fully. Conclusion: We have described a patient with a potentially fatal bacteraemia with E. lenta that may have gone unnoticed. More case reports are necessary, not only to understand the pathogenicity and clinical course of infections by this neglected bacterium, but also to investigate its digoxin degradation and antimicrobial susceptibility variability.

Su1651 Clinical Evaluation of Tokyo Guidelines 2013 for Severity Assessment of Acute Cholangitis

The Tokyo guidelines 2013 (TG13) provide new severity assessment criteria for acute cholangitis (AC) that clearly differentiate between moderate AC and mild AC so as not to miss the optimal timing for biliary drainage. The aim of the study was to evaluate the severity assessment criteria for AC of TG13 and developed a scoring system for predicting the need for urgent/early biliary drainage.

Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde cholangiopancreatography.

Background. The safety of non-anesthesiologist-administered propofol (NAAP) sedation in emergent endoscopic retrograde cholangiopancreatography (ERCP) has not been fully clarified. Thus, the aim of this study was to assess the safety of NAAP sedation in emergent ERCP. Materials and Methods. We retrospectively analyzed 182 consecutive patients who had obstructive jaundice and who underwent ERCP under NAAP sedation. The patients were divided into Group A (with mild acute cholangitis or without acute cholangitis) and Group B (moderate or severe acute cholangitis). And technical safety and adverse events were assessed. Results. The adverse events were hypoxia (31 cases), hypotension (26 cases), and bradycardia (2 cases). There was no significant difference in the rate of each adverse event of hypoxia and bradycardia in either group. Although the rate of transient hypotension associated in Group B was higher than that in Group A, it was immediately improved with conservative treatment. Moreover, there were no patients who showed delayed awakening, or who developed other complications. Conclusions. In conclusion, NAAP sedation is feasible even in emergent ERCP. Although some transient adverse events (e.g., hypotension) were observed, no serious adverse events occurred. Thus, propofol can be used in emergent ERCP but careful monitoring is mandatory.

Clinical evaluation of the Tokyo Guidelines 2013 for severity assessment of acute cholangitis.

We evaluated the severity assessment criteria for acute cholangitis (AC) of the Tokyo Guidelines 2013 (TG13) and developed a scoring system for predicting the need for urgent/early biliary drainage. We retrospectively reviewed 66 AC cases prospectively managed based on the TG07 and divided into an urgent/early biliary drainage group (n = 30) and elective biliary drainage group (n = 36). There were 26 mild, 27 moderate, and 13 severe cases based on the TG13. The TG13 assessment in 12 of the 17 cases requiring early biliary drainage based on the TG07 was moderate, but underestimated the other five cases as mild AC. When five predictors (blood urea nitrogen >20 mg/dL, SIRS presence, platelet count <120 000/μL, serum albumin level <3.0 g/dL, age ≥75 years old) were used to devise a scoring system, the receiver-operator characteristic curve of the scores showed good test performance for predicting the need for urgent/early biliary drainage. The area under the curve (AUC) was 0.95 and higher than the TG13 AUC (0.80). The TG13 is practical, but some AC cases requiring urgent/early biliary drainage were underestimated as mild AC. The scoring system allows identification of high-risk AC patients and will improve the TG13.

The role of procalcitonin in patients with different severity grades of acute cholangitis

Objective To evaluate the role of procalcitonin in patients with different severity grades of acute cholangitis (AC).Methods A retrospective study was carried out on 147 patients with different severity grades of AC who were treated from May 2012 to November 2013 at the Dongyang People's Hospital.Results Of 147 patients,the PCT concentrations were (165.63 ± 32.67) pg/ml,(348.97 ± 45.78) pg/ml,(758.91 ± 28.94) pg/ml for patients with mild,moderate and severe AC respectively.The PCT concentrations were significantly higher in patients with severe AC than those with moderate AC (P ＜ 0.05),and also in patients with moderate AC than those with mild AC (P ＜ 0.05).The top three bacteria obtained from blood culture from the different severity grades of AC showed no significant diferences (P ＞ 0.05).Conclusion Serum PCT concentrations were elevated in patients with AC and it may be used as a parameter to assess the severity of AC. Key words: Procalcitonin; Acute cholanglitis ; Severity gradation

Diagnostic accuracy of transient hepatic attenuation differences on computed tomography scans for acute cholangitis in patients with malignant disease.

Few reports have assessed the accuracy of transient hepatic attenuation differences (THAD) in the arterial phase of computed tomography (CT) in diagnosing acute cholangitis (AC). We examined the diagnostic accuracy of THAD in AC in patients with malignant disease. We retrospectively examined the records of 123 consecutive patients (73 men, 50 women; mean age, 69 [range, 43-91] years) who underwent dynamic CT 3 days before biliary drainage for malignant hepatobiliary disease between 2006 and 2011. We examined the diagnostic ability of THAD for AC and assessed the relationship between THAD and AC severity. Acute cholangitis was present in 45% of patients. The sensitivity and specificity of THAD for AC were 93% and 39%, respectively. Diffuse, hemi-hepatic, and segmental THAD for AC were seen in 84%, 4%, and 9%, respectively. In all, 64% of patients were diagnosed with severe AC and 29% with mild AC, depending on the intensity of THAD, but the patterns and degree of intensity of THAD and AC severity were not related. Although the pattern and the degree of intensity of THAD and AC severity were not related, THAD might be useful in diagnosing AC. Thus, THAD should be considered a diagnostic criterion for AC.

Serum levels and roles of high mobility group box-1 protein in patients with acute suppurative cholangitis

Objective To observe the serum levels of high mobility group box-1 protein （ HMGBI ） in patients with acute cholangitis （AC） and to investigate contributions of HMGB1 in AC. Methods Serum HMGB1 concentrations were determined by an enzyme-linked immunosorbent assay in 30 patients with AC of severe type （ACST） and 42 patients with mild acute cholangitis at the time of admission （ within 72 h after the onset）. A total of 50 heahhy subjects were recruited as the control group. Fluorescent quantitative PCR （FQPCR） was used to detect the HMGB1 mRNA expression and the relationship between serum HMGB1 levels and clinical factors was analyzed. Results The serum HMGB1 levels in healthy control group, mild group and ACST group were （ 1.82 ± 0. 64） μg/L, （ 10. 46 ± 3.75 ）μg/L, （ 18. 89 ± 6. 86 ） μg/L, respectively. The mean value of serum HMGB1 level in mild group was significantly higher than that in control group, while significantly lower than that in ACST group （ P 〈 0. 05 ）. Compared to the control group, the HMGB1 mRNA level in patients of AC increased significantly and the level of ACST group was higher than that of mild group. The serum HMGB1 levels of patients with positive bile or/and blood cultures were higher than that of negative. After emergency endoscopic nasal biliary drainage, the serum HMGB1 levels of pa- tients significantly decreased compared to preoperational （P 〈 O. 05 ）. The HMGB1 levels were significantly positively correlated with white cell counts, C-reactive protein （CRP） , total serum bilirubin, direct bilirubin and alkaline phosphatase （ALP）. By logistic regression analysis, serum HMGB1 levels had correlation with severity of disease. Conclusion Serum HMGB1 levels significantly increased in patients with AC and the serum concentrations of ACST group were higher than those of mild group. Serum HMGB1 level has a correlation with sepsis. ENBD could lower its serum levels. Serum HMGB1 has predictive value to severity of disease. Key words: Cholangitis, Acute ; High mobility group proteins ; Drainage ; Forecasting

Usefulness of Procalcitonin for Severity Assessment in Patients with Acute Cholangitis

The aim of the present study was to examine the usability of procalcitonin (PCT) for severity assessment in patients with acute cholangitis (AC). Serum PCT concentrations were measured on admission in patients with AC. Patients were classified with mild, moderate, or severe AC based on severity assessment guidelines. We included 159 treatment-naïve patients with AC (95 males, 64 females) in this study. The median PCT concentrations were 0.08 ng/mL (interquartile range (IQR) 0.04 - 0.18 ng/mL), 0.37 ng/mL (IQR 0.15 - 1.85 ng/mL), and 5.56 ng/mL (IQR 3.59 - 25.89 ng/mL) in patients with mild, moderate and severe AC, respectively. PCT concentrations were significantly higher in patients with severe AC than in patients with moderate AC (p < 0.0001), and in patients with moderate AC than in patients with mild AC (p < 0.0001). The areas under the receiver operating characteristic curves for PCT to discriminate patients with moderate and severe AC were 0.84 (95% CI 0.77 to 0.92, p < 0.001) and 0.86 (95% CI 0.78 to 0.92, p < 0.001), respectively. Serum PCT concentrations were elevated in patients with AC and may be a useful parameter for the severity assessment of AC.

Risk factors and classification of acute suppurative cholangitis.

A prospective study was performed in 1282 patients with common bile duct stones to determine the clinical and laboratory parameters that could predict cholangitis, and the factors associated with greater severity of cholangitis. Patients were divided into two groups, with or without acute cholangitis, depending on the macroscopic appearance of bile aspirated from the common bile duct during surgery. Acute cholangitis was diagnosed when the aspirated fluid was turbid or clearly pus; the typical Charcot's triad was present in only 22 per cent of patients with acute cholangitis. Several clinical and laboratory parameters were significantly more common in these patients and, depending on their number, the probability of acute cholangitis increased significantly. The operative mortality rate was 1.2 per cent for patients without cholangitis and 11.9 per cent for patients with cholangitis. Depending on the number of factors present, patients with cholangitis were divided into three groups: mild acute cholangitis without mortality; moderate acute cholangitis with a mortality rate of 5.6 per cent; and severe acute cholangitis with a mortality rate of 27.5 per cent. The present classification allows the group of patients needing prompt endoscopic or surgical drainage to be identified.