Severe Acute Cholangitis Research Articles

Clinical evaluation of the Severity Assessment of the Tokyo guidelines and JPN guidelines for severe acute cholangitis

Clinical evaluation of the Severity Assessment of the Tokyo guidelines and JPN guidelines for severe acute cholangitis

Les hépatites virales E : une maladie émergente en France

Hepatitis E virus (HEV) is a RNA enterically transmitted virus that causes large waterborne epidemics of acute hepatitis E in endemic regions (Asia and Africa). Sporadic hepatitis E is an emerging disease in developed countries such as France. The majority of acute hepatitis E in France is indigenous (non travel-associated) and is due to infection with HEV genotype 3. Diagnosis is made on the presence of specific serum antibodies and on viral RNA detection in serum or stools. Characteristic pathological signs of acute hepatitis E are severe intralobular necrosis, polymorph inflammation and acute cholangitis in portal tract with numerous neutrophils. Severe forms of hepatitis are associated with underlying chronic liver disease such alcoholic disease. In immunocompetent patients, HEV causes acute resolutive hepatitis and there is no chronic evolution. Conversely, chronic hepatitis E is frequent in immunocompromised patients with a risk of rapid evolution to cirrhosis. Histologic lesions of chronic hepatitis E are similar to those observed in patients chronically infected with hepatitis C virus with dense lymphocytic portal infiltrate, constant peacemeal necrosis and fibrosis.

Treatment of acute severe cholangitis with duodenoscopy in combination with PTCD

急性重症胆管炎(acute and severe cholecystitis,ACST)是腹部外科常见严重急腹症,急症手术病死率高.内镜下鼻胆管引流(endoscopic nasbiliary drainage,ENBD)已成为ACST的首选治疗[1],浙江省舟山市人民医院肝胆外科从1995年10月至2008年10月,对十二指肠镜治疗后24～48 h内临床症状未缓解的35例ACST病人,行经皮肝穿刺胆管造影引流(percutaneous transhepatic cholangial drainage,PTCD),现报告如下。

The Effectiveness of Emergency Endoscopic Retrograde Cholangiopancreatography in Patients with Severe Acute Cholangitis

Background: The aim of this study was to assess the frequency, indications, yield and outcome of emergent endoscopy retrograde cholangiopancreatography (ERCP) in severe acute cholangitis patients. Method: Records of all cholangitis patients undergoing ERCP were reviewed over a six months period. Indications, findings, therapeutic interventions and survival were analyzed. Indications for urgent drainage were temperature greater than 38oC, increasing abdominal pain, jaundice and any organ involvement. Results: Of 80 ERCPs, 19 (23.75%) were severe acute cholangitis patients underwent emergency ERCP. The common bile duct was the duct of interest in all patients and was cannulated in 100%. The most common findings were choledocholithiasis (42.1%) and pancreatic head cancer (42.1%), followed by cholangiocarcinoma (10.5%) and papil vater carcinoma (5.3%). There were 12 (63.2%) septic shock patients with systolic blood pressure less than 90 mmHg and heart rate greater than 90 beats/minute who required inotropic drugs. Endoscopic biliary drainage was performed using 8.5 F biliary stent (73.7%) or common bile duct (CDB) stones removal (26.3%). The overall 30 days mortality was 0. Conclusion: Emergency ERCP in severe acute cholangitis is associated with improvement of clinical and some laboratory parameters without a complication of acute pancreatitis. In cases of chIoledocholithiasis, it can be performed with stone extraction as well as stent insertion Keywords: severe acute cholangitis, emergent ERCP, endoscopic stenting in difficult hilar biliary stricture

Nasobiliary drainage and percutaneous injection sclerotherapy with minocycline for obstructive jaundice due to polycystic liver disease : A case report

Polycystic liver disease is confirmed in 0.1-0.5% of adults examined at autopsy. Most of them present with a subclinical form of the disease while alive. This time, we experienced a rare case of a patient with polycystic liver disease complicated by obstructive jaundice. To our knowledge, only 14 such cases have been reported. In general, the treatments include operation (fenestration and/or cyst resection), biliary drainage (percutaneous or endoscopic), and percutaneous injection sclerotherapy. Our case was complicated by severe acute cholangitis, and therefore, we first performed emergency nasobiliary drainage. Thereafter, we performed percutaneous injection sclerotherapy with minocycline. Because of absence of intracystic bleeding or infection, it was difficult to identify the cysts that resulted in obstructive jaundice. However, with the aid of a nasobiliary drainage tube, we successfully punctured the cysts that caused obstructive jaundice.

Endoscopic treatment of severe acute cholangitis accompanied with multiple organ dysfunction syndrome

Objective To evaluate the endoscopic managements of acute cholangitis of severe type （ACST） accompanied with multiple organ dysfunction syndrome （MODS）. Methods A total of 122 ACST patients accompanied with MODS from January 2000 to October 2008 underwent endoscopic treatment in two time periods. In critical phase, emergent endoscopic retrograde cholangiopancreatography （ERCP） plus endoscopic naso-biliary drainage （ENBD） were performed to correct critical situation of the patients. After stabilization, endoscopic sphincterotomy （EST） plus stone removal, EST plus stent placement, or laparoscopy was performed according to the causes of ACST. Results Emergent endoscopic managements succeeded in all patients of critical phase. At third day post-operation, a reduction in white blood cell count, serum total bilirubin, body temperature, and rate of patients with shock, mental symptoms and purulent bile juice was achieved. Recovery rate of dysfunction organs was 60.2% at one week after emergent procedure, and 82.6% at 2 weeks post-operation. Selective EST plus stone removal was performed in 36 patients with a success rate on one session at 91.7%. Laparoscopic cholecystectomy was performed in 85 patients with a success rate of 95.3%. Stent was placed in 16 patients with an effective rate of 81.3% at 3 months post the procedure. No severe complication or death occurred during the whole therapeutic course. The 6-month survival rate of 10 cancer cases was 70%. Conclusion Therapeutic ERCP plus ENBD is the first choice for acute severe cholangitis accompanied with MODS, while EST plus biliary lithotomy, or EST plus stent placement, or combined laparoscopy are ideal methods for subsequent treatment. Key words: Cholangitis; Multiple organ dysfunction syndrome; Endoscopic therapy

Elderly patients with acute eholangitis of severe type of clinical observation and care

Objective To investigate elderly patients with acute cholangitis of severe type of clinical observation and care. Methods 56 cases of severe acute cholangitis in elderly patients with medical and nursing measures were analyzed retrospectively. Results 56 eases of severe acute cholangitis in elderly patients are undergoing surgery and the exquisite and meticulous postoperative care,54 were cured and discharged,and discharged two cases improved. Conclusions Elderly patients with acute severe cholangitis are surgical emergency,timely surgical treatment,to strengthen the post-operative care is to improve the success rate and reduce complications and mortality in an effective way. Key words: Aged; ACST; Nursing

Spontaneous migration of a prosthetic mesocaval shunt to the duodenum: endoscopic diagnosis of an unusual complication of shunt surgery

A 21-year-old woman presented with acute severe cholangitis that was treated with intravenous antibiotics and nasobiliary drainage followed by biliary stenting. Subsequent investigation revealed features of extrahepatic portal vein obstruction with a thrombosed splenoportal axis and portal biliopathy as evidenced by dilated intrahepatic biliary ducts, multiple strictures of the extrahepatic bile duct with no filling defects, and venous collaterals around the gallbladder and the common bile duct.

Relation of endotoxic hepatic injury with expression of scavenger receptor A in liver tissue during severe acute cholangitis

Relation of endotoxic hepatic injury with expression of scavenger receptor A in liver tissue during severe acute cholangitis

Diagnosis and treatment of intrahepatic severe acute cholangitis: an analysis of 32 cases

目的 探讨肝内型重症急性胆管炎(ACST)的诊治经验.方法 总结2001-2006年重庆三峡中心医院收治的32例肝内型重症急性胆管炎病人的临床资料.结果 5例经保守治疗缓解后行择期手术,2例经PTCD治疗缓解后行择期手术,25例行急诊手术;术后2例死亡,其余病人均达到解除梗阻、通畅引流的目的.结论 肝内型ACST的梗阻部位影响病人的临床表现及预后,大多数病人需要作急诊手术,应根据梗阻部位来选择合适的治疗方式。

Chirurgische Infektionen der Gallenblase und der Gallenwege

Acute cholecystitis and acute cholangitis are the most frequent surgical infections of the biliary tree. Early laparoscopic cholecystectomy is the treatment of choice in acute cholecystitis. Laparoscopic operation results in a shorter length of stay and less morbidity. Conversion rate is low in early laparoscopic cholecystectomy. Endoscopic or transhepatic decompression of the bile ducts is the treatment of choice in severe acute cholangitis. While the removal of stones is the causal therapy in choledocholithiasis, further diagnosis and consecutive therapy has to follow after decompression of bile duct stenosis.

Liver histology in patients with sporadic acute hepatitis E: a study of 11 patients from South-West France

Hepatitis E virus is a ribonucleic acid (RNA) enterically transmitted virus that causes both epidemics and sporadic cases of acute hepatitis E in many countries of Asia and Africa. Domestically acquired (non-travel-associated) hepatitis E has been reported recently in many industrialized countries including the USA, Europe, and Japan. There is little information available on liver histology in these patients. We report a series of 11 patients with sporadic acute hepatitis E and needle liver histology in South-West France. Hepatitis E was diagnosed based on elevated transaminases (>10 upper limit normal) and the presence of specific serum antibodies (immunoglobulin-G class, present in all 11 patients) and/or viral RNA detection in serum and/or stools. Acute hepatitis lesions were observed in all cases with marked necro-inflammatory activity in nine patients. Confluent necrosis was present in five cases. Anisocaryosis and Kupffer's cell aggregates with siderosis were observed in most of the 11 patients. Cholangitis was frequent (9/11 cases). Cholestasis was observed in eight cases. Pseudo-glandular pattern was present in only one case but without zonal repartition. Characteristic pathological signs of acute hepatitis E were severe intralobular necrosis, polymorph inflammation, and acute cholangitis with numerous neutrophils.

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient’s general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient’s general medical condition.

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.

Management of severe acute cholangitis

Management of severe acute cholangitis

Roux-en-Y jejunal loop obstruction by a giant stent-related stone following liver transplantation

his is a 14-year-old girl who had suffered frombiliaryatresiasincebirth.AKasaioperationfailed,and she gradually progressed into end-stage liver dis-ease,necessitatinglivertransplantation(LT).Attheageof three, she underwent cadaveric LT in the UnitedStates,whereduringhersurgeryasmallplasticcatheterwasusedtostenttheroux-en-Y(REY)choledochojeju-nostomyanastomosis.Afterhertransplant,shewasfol-lowedupinourinstituteandwasadmittedseveraltimeswith a clinical picture suggestive of recurrent cholangi-tis.Recently, she presented to our emergency roomwith an attack of severe acute cholangitis. Dopplerultrasoundexaminationconfirmedpatencyofallves-sels with minimal biliary dilatation. Percutaneous-transhepatic-cholangiogram was urgently performedandshowedawidelypatentcholedochojejunostomy;however, the REY jejunal loop looked dilated andobstructed with a large, sausage-shaped filling defectthat has a central radio-opaque shadow and isobstructing its caudal end nearby the enteroenteros-tomy (Fig. 1). CT scan of the abdomen was per-formed, and a large, sausage-shaped foreign body(FB) was noticed within the REY jejunal loop; thisFB had a central dense line within, suggestive ofdense radio opaque material. There also was distaltaperingofthebowelbeyondtheFB,probablyatthejunction of REY loop with the small bowel (site ofenteroenterostomy). On the other hand, the proxi-mal portion of the REY jejunal loop nearby wasnoted to be dilated, indicating obstruction of theREY jejunal loop by this FB. The patient was takento the operating room, and the large FB was feltwithintheREYjejunalloop,causingpartialobstruc-tion of lumen as indicated by the distension of theproximalportionandcollapseoftheloopbeyondtheFB. The jejunal loop was opened and a large stonewas surgically delivered from within the REY jejunalloop. This stone seemed to obstruct the REY jejunalloop at the site of entero-enteric anastomosis. Exam-ination of the stone showed that it was a 7 2.52.7 cm mixed stone (calcium palmitate 50% andbilirubin 50%) formed around a 5-cm plastic biliarystent (Figs. 2 and 3). Apparently, the small plastictube that was used to stent the biliary anastomosisduring the LT procedure failed to migrate throughthe distal end of the REY jejunal loop, where it wasimpacted and acted as a nidus for the formation ofthis giant mixed stone over a 12-year period follow-ing LT. The patient recovered well from the surgery;her liver functions normalized, and up until now thepatient did not suffer from any further attacks ofcholangitis.This case describes a late life-threatening compli-cation that is related to the use of an internal biliarycatheter to stent the REY biliary anastomosis. Manystudies have shown a significant number of stent-related morbidities and even mortalities.

Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases.

Endoscopic biliary drainage is an established mode of biliary decompression in patients with acute cholangitis as a result of biliary obstruction secondary to stones and benign strictures. However, there are no reports on endoscopic management of severe acute cholangitis caused by malignant conditions. We prospectively compared the efficacy of the endoscopic drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. Forty-three patients with severe acute cholangitis requiring urgent biliary drainage were included. Sixteen patients (mean age 58.2 +/- 9.3 years; seven men, nine women) had biliary obstruction as a result of malignant diseases and 27 had benign biliary diseases (mean age 41.6 +/- 14.3 years; nine men, 18 women). Indications for urgent drainage included any one of the following: temperature >38 degrees C (n = 21), septic shock with systolic blood pressure <100 mmHg (n = 9), localized peritonism (n = 21), impaired consciousness (n = 6) and failure to improve within 72 h of conservative management (n = 13). After successful bile duct cannul degrees ation, patients received either a nasobiliary catheter (n = 38) or an in-dwelling stent (n = 5) with or without sphincterotomy for biliary drainage. Outcome measures included complications and clinical response. Endoscopic drainage was established successfully in all the patients in both the groups. Clinical improvement after biliary drainage occurred in 94% patients (15/16) in the malignant group compared with 96% patients (26/27) in the benign group (P = not significant [NS]). Fever subsided at a median of 2.2 days in the malignant group and at 1 day in the benign group (P = NS). Normalization of leukocyte count was seen at a median of 6 days (range 1-17) and 2 days (range 1-5) days in the malignant group and the the benign group, respectively (P = NS). There were no endoscopic retrograde cholangiopancreatography-related complications. The mortality rate as a result of cholangitis was 4.6%, that is two of 43 patients (6.2% of the malignant group vs 3.7% of the benign group; P = NS). Endoscopic biliary drainage is equally effective in patients with severe acute cholangitis caused by either malignant or benign biliary diseases.

Outcome of emergency ERCP for acute cholangitis in patients 90 years of age and older.

An increasing proportion of the general population across the Western World now survives to an advanced age. However, there is limited data on the outcome of therapeutic endoscopic retrograde cholangiopancreatography in patients above 90 years of age with severe acute cholangitis. To determine the relative frequency of postendoscopic retrograde cholangiopancreatography complication in this group of patients. The postendoscopic retrograde cholangiopancreatography complications related outcome of 64 patients aged 90 years and above (Group 1) with severe acute cholangitis were retrospectively compared with 165 patients under the age of 90 years (Group 2). The postendoscopic retrograde cholangiopancreatography complication rate was 4.7% (three patients) in Group 1 and 7.3% (12 patients) in Group 2. There was no significant difference in the postendoscopic retrograde cholangiopancreatography complication rate between the two groups (P = 0.567). The relative frequency of 30-day mortality was 7.8% (five patients) in Group 1 and 4.2% (seven patients) in Group 2 (P = 0.227). Urgent biliary decompression with endoscopic retrograde cholangiopancreatography in patients 90 years of age and older with severe acute cholangitis is a safe and effective procedure in the hands of highly skilled endoscopists and is not associated with increased morbidity or mortality even in this group of high risk patients.

Clinical features of acute severe obstructive suppurative intrahepatic cholangitis

目的 提高对重症急性梗阻性化脓性肝胆管炎(单纯肝内胆管梗阻的重症胆管炎称肝内型ACST)的诊断治疗水平,减少其死亡率.方法回顾1991～2000年本院收治的186例重症胆管炎(ACST)中28例肝内型ACST的临床资料,对其临床表现和治疗进行分析探讨.结果 28例肝内型ACST出现明显腹痛8例,黄疸12例;158例胆总管型ACST出现Charcot三联症149例.将两组的腹痛和黄疸发生率行χ2检验,两组差异有显著性(P＜0.01).结论肝内胆管梗阻的重症胆管炎临床表现和治疗有一定的特殊性,早期诊断、及时手术能减少其死亡率。

Clinical analysis of 38 aged patients with acute severe cholangitis

目的 探讨老年急性重症胆管炎(ASC)病人的手术治疗效果及死亡原因.方法回顾性分析38例老年ASC病人的治疗及预后情况.结果围手术期死亡6例,病死率15.8%.在中毒性休克6 h内行手术者全部存活,超过24 h 3例,均于术后1～3 d死于中毒性休克、多器官功能衰竭.结论 ASC病人应在出现休克或精神症状之前采用手术治疗,越早手术效果越好,以手术为主的综合治疗是降低ASC病死率的有效措施;延误手术时机、高龄、合并症是死亡的主要原因。