Purulent Cholangitis Research Articles

Особливості перебігу спонтанних внутрішніх біліарних нориць

Spontaneous internal biliary fistulas (SIBF) is one of the complications of gallstone disease (GD), as well as inflammatory, degenerative-dystrophic and oncological diseases of organs located close to the hepatobiliary zone – such as the stomach, duodenum, small intestine and small intestine, other organs The frequency of cholecystial cholecystectomy was 84 patients (43.6%), of which 76 (91.5%) and 8 (8.5%) patients had Myrizzi (SM) type I and type II syndrome. Mechanical jaundice and choledocholithiasis were observed most frequently in patients with SIBF -86 (44.7%) and 80 (41.6%) patients. In the second place purulent cholangitis in 9 (4.6%) and acute pancreatitis was found in 6 (3.1%). The main choice of surgical intervention is cholecystectomy 132 (69%), along with choledochotomy and late extraction 107 (56%).

Ciprofloxacin in therapy and prevention of purulent infections in patients with the hepatobiliary deseasre

The aim — to study the ciprofloxacin effectiveness in the treatment and prevention of purulent complications in patients with acute surgical pathology of the digestive system.Materials and methods. 85 patients with the pathology of the hepatopancreatobiliary system, which was administered сiprofloxacin (Ciprolet) were observed in the department of laparoscopic surgery and cholelithiasis for the period from 2012 to 2017.Results and discussion. The use of ciprofloxacin in patients with hepatopancreatoduodenal disease was effective in the prevention and treatment of purulent‑septic complications. Only 3 (3.8 %) patients who had undergone surgery on the biliary tract had suppuration of the postoperative wound. There were no cases of peritonitis progression. Intestinal peristalsis was restored on average 4.10 ± 0.08 day after the operation, body temperature and leukocyte count were normalized at 5.10 ± 0.09 day.Conclusions. The use of ciprofloxacin in patients with acute surgical pathology of the hepatopancreatobiliary system and the obstruction of the bile ducts of non‑tumorous genesis complicated by purulent cholangitis and mechanical jaundice is characterized by high clinical efficacy.

Sa1423 - Tokyo Guidelines Fail to Predict Patients with Severe Purulent Cholangitis

Sa1423 - Tokyo Guidelines Fail to Predict Patients with Severe Purulent Cholangitis

Modern Approaches to Antibiotic therapy in Acute Cholangitis

Objective — to study microflora characteristics in bacteriological study of bile, and to determinate the sensitivity of this microflora to modern antibacterial agents.
 Materials and methods. In 43 operated patients with acute purulent cholangitis for bacteriological examination, a bile was collected from the lumen of the common bile duct during the open surgical operation on extrahepatic bile ducts, also from the choleldosostomy drainage tube in the postoperative period and during retrograde endoscopic diagnostic and therapeutic manipulations. Antibiotic susceptibility of aerobic microorganisms was determined by the disc diffusion method, anaerobic — using АТВ ANA test systems.
 Results and discussion. It is established that the structure of microflora, which cultivated with the test material, the main place occupied mainly aerobic bacteria Escherichia group (51 %). In cultivated microbial associations manifested dominance of gram-negative microorganisms and bacteria of the type of anaerobic metabolism. The highest level of sensitivity of aerobic microorganisms to antibiotics manifested itself with preparations of the group of cephalosporins III—IV generation, fluoroquinolones II—III generation and carbapenems — in 68 %, 62 % and 87 % of observations, respectively. Sensitivity of microorganisms to preparations of cephalosporin І generation was observed only in 19 % and II — in 20 % of cases. The assessment of antibiotic susceptibility of anaerobic microflora showed virtually absolute levels to protected penicillins (piperacillin + tazobactam, ticarcillin + clavulanic acid). And the sensitivity of these microorganisms to imipenem, cefotaxime and clindamycin was 97 %, 91 % and 94 %, respectively.
 Conclusions. In the structure of the microflora in acute purulent cholangitis, aerobic bacteria of the intestinal group and gram-negative microflora with anaerobic type of metabolism prevailed.Aerobic microorganisms exhibited high antibiotic susceptibility to cephalosporins of the III—IV generation, fluroquinolones of the II—III generation and carbapenems, and anaerobic bacteria — protected penicillins, cephalosporins and carbapenems. Etiotropic antibiotics should be administered within 10—14 days.

A Novel Protocol Obviates Endoscope Sampling for Carbapenem-Resistant Enterobacteriaceae: Experience of a Center with a Prior Outbreak.

Numerous published outbreaks, including one from our institution, have described endoscope-associated transmission of multidrug-resistant organisms (MDROs). Individual centers have adopted their own protocols to address this issue, including endoscope culture and sequestration. Endoscope culturing has drawbacks and may allow residual bacteria, including MDROs, to go undetected after high-level disinfection. To report the outcome of our novel protocol, which does not utilize endoscope culturing, to address our outbreak. All patients undergoing procedures with elevator-containing endoscopes were asked to permit performance of a rectal swab. All endoscopes underwent high-level disinfection according to updated manufacturer's guidance. Additionally, ethylene oxide (EtO) sterilization was done in the high-risk settings of (1) positive response to a pre-procedure risk stratification questionnaire, (2) positive or indeterminate CRE polymerase chain reaction (PCR) from rectal swab, (3) refusal to consent for PCR or questionnaire, (4) purulent cholangitis or infected pancreatic fluid collections. Two endoscopes per weekend were sterilized on a rotational basis. From September 1, 2015 to April 30, 2016, 556 endoscopy sessions were performed using elevator-containing endoscopes. Prompted EtO sterilization was done on 46 (8.3%) instances, 3 from positive/indeterminate PCR tests out of 530 samples (0.6%). No CRE transmission was observed during the study period. Damage or altered performance of endoscopes related to EtO was not observed. In this pilot study, prompted EtO sterilization in high-risk patients has thus far eliminated endoscope-associated MDRO transmission, although no CRE infections were noted throughout the institution during the study period. Further studies and a larger patient sample will be required to validate these findings.

ДИФЕРЕНЦІЙОВАНИЙ ПІДХІД ДО ЛІКУВАННЯ ХВОРИХ З ГОСТРИМ ХОЛАНГІТОМ, УСКЛАДНЕНИМ БІЛІАРНИМ СЕПСИСОМ

Гнійний холангіт – одне з найчастіших і найтяжчих ускладнень доброякісних і злоякісних захворювань жовчних шляхів.Мета дослідження – покращення результатів хірургічного лікування хворих із гострим холангітом шляхом диференційованого застосування міні-інвазивних методів попередньої декомпресії жовчовивідних шляхів та удосконаленого методу детоксикації – плазмаферезу.Матеріали і методи. Дослідження проводили на базі клініки Самаркандського державного медичного інституту. Було включено 217 пацієнтів із гіпербілірубінемією, гострим холангітом, біліарним сепсисом і тяжким біліарним сепсисом. Для 17 пацієнтів (перша група) застосовували традиційне лікування з інфузійною та антибіотикотерапією; для 18 хворих (друга група) було застосовано плазмаферез у поєднанні з непрямою електрохімічною оксигенацією (НЕХО) плазми гіпохлоритом натрію; ще для 18 пацієнтів (третя група) з додатковим озонуванням плазми (ПА з НЕХО + Озон) із наступною реінфузією детоксикованої плазми.Результати досліджень та їх обговорення. У хворих із тяжким ступенем ендогенної інтоксикації у післяопераційному періоді найбільш тяжко виражений ендотоксикоз та поліорганна недостатність були у хворих першої групи. В той час як серед пацієнтів другої та третьої груп відмічалися кращі результати хірургічного лікування завдяки розробленому лікувально-діагностичному алгоритмові.Висновки. Розроблена диференційна двоетапна хірургічна тактика з виконанням міні-інвазивних декомпресій та із застосування плазмаферезу дозволяє купірувати явища ендотоксикозу, холестазу та дисфункції печінки, таким чином поліпшуючи результати лікування хворих із гострим холангітом.

Comparative evaluation of interleukin-6 in the liver tissues, bile duct, blood serum and urine in patients with obstructive jaundice of benign etiology

Цель исследования – сравнительное изучение содержания IL-6 в ткани печени, протоковой желчи, сыворотке крови и мочеу больных с ОЖ доброкачественного генеза, в зависимости от степени печеночной дисфункции.Материалы и методы. В статье в сравнительной оценке анализируются содержание IL-6 в ткани печени, сывороткекрови и протоковой желчи в динамике при хирургическом лечении 67 больных с обтурационной желтухой доброкачествен-ного генеза. У всех больных причиной обтурационной желтухи был холедохолитиаз. Степень печеночной дисфункции опре-деляли с учетом маркеров холестаза и цитолиза гепатоцитов в крови. Печеночная дисфункция I степени наблюдалась – у21 больного, печеночная дисфункция II степени – у 14, печеночная дисфункция III степени – у 10, печеночная дисфункция IV– у 9 больных. У 13 больного на фоне обтурационной желтухи был гнойный холангит. Концентрацию IL-6 в ткани печени(ТП), при заборе во время операции у 42 больных, в протоковой желчи сразу – в первой порции у 42 больных, на 3-и и 7-есутки после наружной декомпрессии желчных путей у 37 больных, в сыворотке крови и моче до операции, на 3-и и 7-е суткипосле операции определяли с помощью иммуноферментного анализа с использованием реактивов Dender Medsistems (USA).Результаты и их обсуждения. Сопоставление показателей IL-6 в ТП, протоковой желчи, сыворотке крови и моче у боль-ных различной степенью ПД показало, что сыворотка крови характеризовала более низким их уровнем содержания данно-го показателя, чем в ТП, желчи и моче, а больше всего данного цитокина определилось в желчи. При наличии ГХ наблюда-ется наибольшее накопление IL-6 в ТП, желчи и в моче по сравнению с сыворотке крови.Вывод Локальный и системный уровни IL-6 могут служить в качестве маркеров для оценки тяжести патологическогопроцесса, планирования консервативной терапии, мониторинга эффективности проводимого лечения и клинического те-чения.Ключевые слова: механическая желтуха, холедохолитиаз, интерлейкин – 6, печеночная дисфункция

DIRECTED CYTOKINE THERAPY IN COMPLEX TREATMENT OF PATIENTS WITH OBSTRUCTIVE JAUNDICE OF CHOLELITHIC GENESIS

The article analyzed the results of surgical treatment of 137 patients with obstructive jaundice of benign genesis. An immune status was studied in serum in dynamics before surgery. The rates of CD3, CD4, CD8, CD19, Ig A, M, G were determined on the first, third, seventh and fourteenth days after operation. The levels of TNFα, IFNγ, IL-2, IL-6, IL-4, IL-10 were investigated in serum and at the same time TNFα, IL-4, IL-6 were noted in the bile duct and IL-6 - in urine. Obstructive jaundice of cholelithiс genesis is characterized by disbalance of immune and cytokine status. The depth of disbalance depends on the degree of hepatic dysfunction and presence of purulent cholangitis. The directed cytokine therapy by ronkoleykin influenced positively on elimination of disbalance in immune and cytokine status and this therapy improved results of surgery in postoperative period.

ACUTE CHOLANGITIS, COMPLICATED BY BILIARY SEPSIS: CLINICAL CASE WITH A FAVORABLE OUTCOME

Now purulent cholangitis has acquired the status of an independent problem on which solution further progress of surgery of a gepatobiliopancreatoduodenal zone depends. Substantially it is caused by increase in number of patients with the complicated cholelithiasis form, especially at elderly people with immunodeficiency and accompanies pathology, tendency to development of a purulent сholangitis and biliary sepsis. The clinical case of the acute purulent cholangitis caused by Klebsiella pneumoniae in the elderly man, and which was complicated by biliary sepsis is presented in article. The surgical decompression of bilious ways in combination with drug therapy (cephalosporin ΙΙΙ generations) was ineffective. The microbiological blood test has helped to specify the activator of septic process, to appoint effective antibacterial therapy that has defined a favorable outcome of a disease at the patient.

The state of cytokine status in patients with mechanical jaundice of benign origin

The results of survey of 67 patients with obstructive jaundice (OJ) of benign origin are analyzedin the article. In all patients the cause of obstructive jaundice was choledocholithiasis. The degree of hepatic dysfunction (HD) was identified taking into account of cholestasis (total serum bilirubin and alkaline phosphatase activity in blood) and cytolysis syndromes (levels of alanine aminotransferase and aspartate aminotransferase). Liver dysfunction degree I was observed in 21 patients, degree II--in 14, degree III--in 10 and degree IV--in 9 patients. In 13 patients OJ was complicated with purulent cholangitis (PCh). Serum concentration of TNF-α, IFN-γ, IL-2, IL-4, IL-6, IL-10 was determined. Cytokine status imbalance was diagnosed in all patients with benign mechanical jaundice on admission. Levels of serum proinflammatory cytokines TNF-α, IFN-γ and IL-6 were greater and the level of IL-2 was lower than those in healthy people. The analysis has showed that severity of cytokine imbalance depends on the degree of LD and level of hyperbilirubinemia. Imbalance in cytokine regulation manifests in disorders of pro- and anti-inflammatory cytokinesratio.

Diagnostic and Therapeutic Value of ERCP in Acute Cholangitis

Cholangitis, with a clinical spectrum between acute ascending cholangitis and acute fulminant cholangitis, the mildest and the most severe forms, respectively, is the infection of bile ducts with a potential of serious mortality and morbidity. Obstruction of the bile ducts followed by infection, with E. coli being the most commonly isolated agent, is common to all forms of cholangitis. Biliary obstruction is caused by choledocholithiasis mostly. “Choledochal pressure” is the most important factor, determining morbidity. If the pressure exceeds 25 cm H2O, which is the critical value, immune dysfunction ensues. Sepsis is common if the infection of biliary ducts is suppurative. Mortality and morbidity are inevitable if left untreated or drained late. The objective of this study is, in the stand point of the current literature, to analyse the diagnostic, therapeutic success and complication rates of ERCP (Endoscopic retrograde cholangiopancreatography) in patients with a diagnosis of acute purulent cholangitis with no response to medical treatment.

Treatment of Metastatic Renal Cell Carcinoma With CAIX CAR-engineered T cells: Clinical Evaluation and Management of On-target Toxicity

Autologous T cells genetically modified to express a chimeric antibody receptor (CAR) against carboxy-anhydrase-IX (CAIX) were administered to 12 patients with CAIX-expressing metastatic renal cell carcinoma (RCC). Patients were treated in three cohorts with a maximum of 10 infusions of a total of 0.2 to 2.1 × 10(9) CAR T cells. CTC grade 2-4 liver enzyme disturbances occurred at the lowest CAR T cell doses, necessitating cessation of treatment in four out of eight patients in cohorts 1 and 2. Examination of liver biopsies revealed CAIX expression on bile duct epithelium with infiltration of T cells, including CAR T cells. Subsequently four patients were pre-treated with CAIX monoclonal antibody (mAb) G250 to prevent CAR-specific toxicity and showed no liver toxicities and indications for enhanced peripheral T cell persistence. No clinical responses were recorded. This report shows that CAIX-targeting CAR T cells exerted antigen-specific effects in vivo and induced liver toxicity at the lowest dose of 0.2 × 10(9) T cells applied, illustrating the potency of receptor-modified T cells. We provide in-patient proof that the observed "on-target" toxicity is antigen-directed and can be prevented by blocking antigenic sites in off-tumor organs and allowing higher T cell doses.

Caudate lobe-sparing subtotal hepatectomy for primary hepatolithiasis

Patients with frequent and life-threatening attacks of cholangitis due to bilateral primary hepatolithiasis with atrophy of the main liver and giant hypertrophy of the caudate lobe were assessed for caudate lobe-sparing subtotal hepatectomy. This was a retrospective study of prospectively collected data from patients who underwent subtotal hepatectomy with sparing of the caudate lobe (resection of 7 liver segments, leaving only the caudate lobe) between March 2003 and December 2009. All patients had concomitant bile duct exploration and choledochoscopy. Perioperative and long-term outcomes were analysed. Immediate stone clearance was obtained in all 12 patients enrolled in the study. Two patients had strictureplasty of the strictured caudate bile duct. There was no hospital mortality and six complications developed in three patients. At a mean follow-up of 51 months, one patient had developed recurrent stones in the caudate lobe bile ducts at 8 months and died from acute purulent cholangitis, 17 months after surgery. The remaining 11 patients were symptom-free with no further attacks of acute cholangitis. In selected patients with bilateral primary hepatolithiasis, caudate lobe-sparing subtotal hepatectomy is a safe and effective treatment.

A peculiar case of autoimmune pancreatitis and sclerosing cholangitis

A 65-year-old man presented with recurrent abdominal pain and slight weight loss. Computed tomography (CT) and endoscopic ultrasound (EUS) revealed a hypodense, partially cystic mass located in the pancreatic body and tail that raised the suspicion of pancreatic cancer (● Fig.1). No distant metastases were detected and the patient underwent surgical resection of the mass and splenectomy, which was complicated by a bleeding splenic artery aneurysm. Surprisingly, only massive inflammation of the pancreas was found on histological examination of the resected specimen. The patient re-presented 1 year later with jaundice for the first time. EUS demonstrated a pseudocyst within the head of the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) revealed an isolated stenosis of the distal common bile duct (● Fig.2a). This was successfully treated with regularly exchanged endoprotheses, leading to a complete normalization of laboratory parameters. The patient returned 2 years later with fever and jaundice. This time ERCP showed a purulent cholangitis with a stricture of the biliary bifurcation as well as several stenotic intrahepatic bile ducts (● Fig.2b). Brush cytology raised a suspicion of cholangiocarcinoma. Serum IgG4 levels, antinuclear antibody (ANA), antineutrophil cytoplasmic antibody (ANCA), anticarbonic anhydrase II and antilactoferrin antibodies were all within the nor

P28.10 Bacteriocholia in dynamics in patients with purulent cholangitis after different methods of external drainage of the common bile duct

P28.10 Bacteriocholia in dynamics in patients with purulent cholangitis after different methods of external drainage of the common bile duct

Severe and fatal complications after ERCP: Analysis of 2555 procedures in a single experienced center

The majority of recent large series on endoscopic retrograde cholangiopancreatography (ERCP) complications have been multicenter studies reflecting varying degrees of experience and ERCP volume; major ERCP complications are associated with low case volume. The aim of this study was to report and analyze the frequency of severe and fatal complications associated with ERCP at a single specialized surgical high-volume referral center (Turku University Central Hospital). All scheduled ERCP procedures (n = 2788) at our unit between January 1997 and December 2005 were included and the procedure-related severe and fatal complications were assessed by retrospective chart review. Complications were classified as severe or fatal according to standardized guidelines. The number of ERCP procedures performed was 2555, of which 71% were therapeutic and 29% were diagnostic. Seventeen (0.8%) severe complications were identified in 16 patients, of whom 15 underwent a therapeutic endoscopic procedure. Of the 17 severe complications, perforation constituted five cases (0.2%), pancreatitis occurred in five patients (0.2%), bleeding in five cases (0.2%), and two patients suffered from purulent cholangitis (0.1%). Procedure-related mortality was 0.08% (n = 3). In our study the rate of severe or fatal complications of ERCP is low in experienced hands at a high-volume center, comparing favorably to corresponding complication rates of multicenter series, which further supports the importance of centralizing ERCP procedures in high-volume advanced centers.

Main complications after major liver resections and possible waysof prevention

Results of 325 major liver resections were investigated. The common indications were malignant and benign lesions, hydatid cysts, purulent cholangitis, posttraumatic liver necrosis. The main complications after liver resections were massive intraoperative bleedings and acute postoperative liver failure. The main causes of blood loss and liver failure were discovered. The most effective means to prevent bleeding was anatomical liver resection. Lobe vascular occlusion is essential for minimal blood loss. Postoperative liver failure was strong associated with the small volume of the remnant liver and decrease in functional liver capacity. Precision selection of patients and preoperative portal vein embolisation lead to decrease the rate of liver failure (5,4%).

Modern approaches to etiology, pathogenesis and treatment of cholangitis andbiliary sepsis

To develop the optimum medical-diagnostic algorithm, allowing to lower the lethality and frequency of complications at patients with acute cholangitis and biliary sepsis. To define interrelation and to reveal distinctions between acute cholangitis and biliary sepsis. Patients with acute cholangitis and biliary sepsis of various severity and etiology; cases history. Development of the given problem will allow to lower lethality at purulent cholangitis and biliary sepsis.

Acute humoral rejection and C4d immunostaining in ABO blood type-incompatible liver transplantation

Complement C4d deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in kidney and other solid organ transplantation. The correlation of C4d deposits and humoral rejection in liver transplants, however, is not well understood. We investigated the C4d immunostaining pattern in 34 patients whose liver biopsy was taken within the first 3 postoperative weeks for suspected acute rejection after ABO blood type-incompatible liver transplantation. The staining pattern was classified as positive (portal stromal staining), indeterminate (endothelial staining only), and negative (no staining). Positive C4d immunostaining was seen in 17 (50%) patients and was significantly associated with high (x64 or more) postoperative antidonor A/B antibody (immunoglobulin M (IgM)) titers (88 vs. 35%, P = 0.002) and poorer overall survival rate (41 vs. 88%, P = 0.007). Ten of 11 (91%) cases with histological acute humoral rejection (periportal edema and necrosis (PEN) or portal hemorrhagic edema) were positive for C4d, all of which showed high postoperative antibody titers. The other histologies associated with C4d positivity was purulent cholangitis (n = 4), coagulative hepatocyte necrosis (n = 1), acute cellular rejection (n = 1), and hepatocanalicular cholestasis (n = 1). Full clinical recovery was observed in only 6 of 17 (35%) C4d-positive patients, and tended to be associated with a lower rejection activity index (RAI). In conclusion, our study indicates that C4d deposits in the portal stroma can be a hallmark of acute humoral rejection in ABO-incompatible liver transplantation, and allograft damage can be reversible in a minority of cases.

Cholestasis in a murine experimental model: lesions include hepatocyte ischemic necrosis.

To establish a murine experimental model of bile duct obstruction that would enable controlled observations of the acute and subacute phases of cholestasis. Adult male isogenic BALB/c mice underwent a bile duct ligation (22 animals) or a sham operation (10 animals). Fifteen days after surgery, or immediately after the animal's death, macroscopic findings were noted and histological study of the liver, biliary tree, and pancreas was performed (hematoxylin-eosin and Masson trichromic staining). Beginning 24 hours after surgery, all animals from the bile duct ligation group presented progressive generalized malaise. All animals presented jaundice in the parietal and visceral peritoneum, turgid and enlarged liver, and accentuated dilatation of gallbladder and common bile duct. Microscopic findings included marked dilatation and proliferation of bile ducts with accentuated collagen deposits, frequent areas of ischemic necrosis, hepatic microabscesses, and purulent cholangitis. Animals from the sham operation group presented no alterations. We established a murine experimental model of induced cholestasis, which made it possible to study acute and subacute tissue lesions. Our data suggests that in cholestasis, hepatic functional ischemia plays an important role in inducing hepatic lesions, and it also suggests that the infectious process is an important factor in morbidity and mortality.