Severe Cholangitis Research Articles

Aspergillus fumigatus cholangitis in a patient with cholangiocarcinoma: case report and review of the literature

Aspergillus spp. cholangitis is an uncommon presentation of invasive aspergillosis. Only few cases are described in the literature affecting severely immunocompromised patients or patients following biliary surgery. Especially, invasive aspergillosis in non-haematological patients is associated with high mortality rates, caused by atypical presentations, which is associated with a delay in diagnosis and therapy. We report a 72-year-old man with primary diagnosis of cholangiocarcinoma and stent implantation by endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression who developed severe cholangitis with invasive aspergillosis. The patient had no history of prior hospitalisation, no immunosuppressive therapy and no preceding biliary surgery. Furthermore, in this exceptional case of extrapulmonary aspergillosis, there were no signs of pulmonary involvement. From the literature review, only three cases of Aspergillus cholangitis could be identified. Clinical manifestations of invasive aspergillosis can be variable and classical risk factors such as immunosuppression are not mandatorily present. Clinical awareness of these rare cases is of vital importance for initiation of correct therapy.

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis

BackgroundLittle is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality. MethodsBi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed. Results85 patients, with a median [Q1–Q3] age of 83 [80–89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1–Q3] ICU length of stay was 3 [2–6] days. Median [Q1–Q3] admission SAPS II was 50 [42–70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4–817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5–0.9]) were associated with higher 6-month mortality. ConclusionIn their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care. Trial registrationNCT03831529.

Role of cholangitis in predicting survival in patients with carcinoma of the ampulla of vater

BackgroundThere have been strong suggestions that acute inflammation promotes tumour growth, and has a tendency for increased invasiveness, leading to poor survival after surgery. When cholangitis coexists with ampulla of vater cancer, the patient's prognosis may be influenced by the acute inflammatory status of the bile duct. We evaluated the relationship between the severity of acute cholangitis, preoperative CRP levels and survival. MethodsWe retrospectively analysed 154 patients who underwent surgical resection for AOV cancer between January 2003 and November 2018. Cholangitis was graded according to Tokyo Guidelines 2018. Patients were categorised into two groups based on their CRP levels: CRP > 1 mg/L and CRP ≤ 1 mg/L. Relationship of cholangitis grade and CRP >1 mg/L with survival was assessed. ResultsThe mean age of the patients was 65.8 years. Preoperative cholangitis was present in 40 (25.9%) patients, of which 28 (18.2%) had mild cholangitis, 11 (7.1%) had moderate cholangitis, and one (0.6%) had severe cholangitis. CRP was elevated preoperatively in 56 (36.4%) patients. The median follow-up period was 33.5 months. Severity of cholangitis significantly affected the overall survival (P < 0.001) and disease-free survival (P < 0.001). Patients with mild cholangitis had a median overall survival of 43 months compared to 14 months in those with moderate cholangitis. A preoperative CRP level of >1 mg/L was significantly associated with poor overall survival (P = 0.023) but not with disease-free survival (P = 0.128), although it was associated with a trend towards poorer survival. The survival rate of patients with CRP ≤1 mg/L was 77.4%, whereas that of patients with CRP >1 mg/L was 56.7%. In multivariable analysis, age >65 years (P = 0.015), cholangitis grade (P = 0.050), CRP > 1 mg/L (P = 0.045), venous invasion (P = 0.005), and perineural invasion (P = 0.034) were independent prognostic factors for overall survival while cholangitis grade (P = 0.049) and perineural invasion (P = 0.004) were independent prognostic factors for disease-free survival. ConclusionAcute inflammation when associated with cancer can have a negative effect on patient's survival. Patients with higher grades of cholangitis should be adequately treated to improve the inflammatory status.

Combining E-PASS model and disease specific risk factors to predict severe morbidity after liver and bile duct resection for perihilar cholangiocarcinoma

BackgroundEstimation of physiologic ability and surgical stress system (E-PASS) has been shown to be effective in predicting morbidity after surgery for perihilar cholangiocarcinoma (PHCC). Nevertheless, E-PASS does not include an assessment of the disease specific risk factors. The aim of the study was to estimate the combined impact of E-PASS and specific preoperative factors on major morbidity for PHCC patients. MethodsA retrospective analysis of a prospectively collected data was performed. Severe morbidity according to complication comprehensive index was defined as ≥40 points. A value of comprehensive risk score (CRS) ≥1 was taken as critical. ResultsMultivariate analysis of perioperative data from 122 patients revealed significant impact of five factors (CRS ≥1, future liver remnant volume <50%, T4 stage, moderate and severe cholangitis, INR) on the risk of severe morbidity after resection. The AUC for the combination of these factors was classified as good predictive value (0.810, 95% CI 0.729–0.891) and poor predictive value (0.673, 95% CI 0.573–0.773) for CRS alone (p = 0.040). ConclusionA combination of E-PASS with disease specific risk factors is a reliable predictive model for major morbidity for patients undergoing radical surgery for PHCC.

Su1264 EUS-GUIDED HEPATICOGASTROSTOMY AS SALVAGE TREATMENT FOR ACUTE CHOLANGITIS SECONDARY TO HILAR MALIGNANT OBSTRUCTION

Unresectable malignant hilar biliary obstruction (MHBO) often cause complicated biliary obstruction requiring a challenging endoscopic biliary drainage. Endoscopic transpapillary stenting using multiple metal stent has been recently reported with high technical and clinical success. However, reintervention with transpapillary endoscopic stenting often encounters technical difficulty in selective intrahepatic biliary cannulation when acute cholangitis occurs in the segmental bile duct beyond the indwelling trasnpaillary metal stents or the severe biliary stricture. EUS-guided hepaticogastrostomy (EUS-HGS) potentially provides effective isolated biliary drainage for MHBO as a therapeutic option. In this study, we evaluated the safety and feasibility of EUS-HGS for acute cholangitis in the segmental bile duct in MHBO patients. We retrospectively investigated the clinical outcome of EUS-HGS in acute cholangitis for MHBO after transpappilary endoscopic approach were failed or supposed to be challenging between April 2015 and Octorber 2019. Technical success rate, the details of the procedure, clinical success rate (resolution of acute cholangitis and reintroduction of chemotherapy), and procedural complications were evaluated. A total of 32 patients were underwent EUS-HGS for MHBO during our study period. Technical success rate was 90.6% (n=29). In technical success 29 patients, 21 were men; the median age was 70 (range from 25 to 94 years old). The puncture sites of the intrahepatic bile duct were B2 (52%), B3 (41%) and B6 (7%). The cancer primary was hilar cholangiocarcinoma (34%), gallbladder cancer (24%), intrahepatic cholangiocarcinoma (17%), pancreatic cancer (17%), and other cancers (17%). ECOG performance status (PS) before EUS-HGS was PS 0, 17%; PS 1, 58%; PS 2, 17%; PS 3, 7%; and PS 4, 0%. Cholangitis severity before EUS-HGS was Grade 1 (mild), 38%; Grade 2 (moderate), 62%; Grade 3 (severe), 0%, based on the criterion of Tokyo Guidelines 2018 (TG18). The stents for EUS-HGS were plastic (83%) and metal (17%). Resolution rate of cholangitis was 89%, and reintroduction rate of chemotherapy was 68%. In better performance status (PS 0-1) or milder acute cholangitis by TG18 evaluation criteria, chemotherapy-resume rate were favorable, compared to poor PS (PS 2-4) (88% vs. 58%, p = 0.06) or more severe acute cholangitis (53% vs. 16%, p = 0.04), in any stent types nor drainage route. Complication rate was observed in 4 cases (13%); 2 abdominal emphysema and 2 liver abscess as late complications. All the adverse events were conservatively managed. In our study, EUS-HGS showed a safe and feasible drainage approach for acute segmental isolated cholangitis in MHBO, when endoscopic trasnpapillary approach failed or became difficult.

Su1556 FEASIBILITY AND SAFETY STUDY OF A TEMPORARY BILIARY STENT FOR PROPHYLAXIS OF POST-ERCP CHOLANGITIS AFTER STONE REMOVAL

Endoscopic treatment of common bile duct stone is usually performed through the major papilla. Despite sphincteroplasty through EST or endoscopic papillary large balloon dilatation (EPLBD), edema of papilla is common after treatment, that may induce cholangitis with cholestasis (post-ERCP cholangitis: PEC). Although few cases of post-ERCP cholangitis progress to severe cholangitis, it can cause prolongation of hospital stay. To avoid this complication, biliary decompression is sometimes necessary in addition to stone removal. In such a case, ENBD or biliary stent are employed, that causes discomfort to the patient, or that requires another endoscopic session to remove the inserted stent. This retrospective study evaluates prophylactic effect of a temporary biliary stent to prevent PEC which dislodges after commencement of oral intake. Between April 2011 and May 2017, endoscopic treatment of common bile duct stones was performed on 2055 naive cases in our hospital. Among them, temporary biliary stents were employed in 190 patients in the first session. To select the patients to compare the feasibility and safety of a temporary stent between stent group and non-stent group in a reduced bias condition, propensity score matching was introduced. As a temporary biliary stent, we used 5Fr.-5cm Geenen type stent (COOK), which has a flap on only one side. After complete stone removal which was checked by balloon occlusion cholangiogram, the deployment of a temporary was decided within operator’s discretion. The PEC was defined as oral intake delay which was decided by fever and abdominal pain with abnormal liver function test. The severity of PEC was classified according to Cotton’s criteria. The dislodgement of deployed stent was confirmed by an abdominal X-ray after oral intake. Other adverse events including post-ERCP pancreatitis were also evaluated. A total of 72 pairs of patients were selected by propensity score matching. The incident rate of PEC in stent group was significantly lower than non-stent group (1.4% vs 11.1%, p=0.033). In all cases, severity of PEC was mild or moderate. The length of hospital stay in stent group were significantly shorter than in non-stent group (6.5 days vs 8.3 days, p=0.038). The rate of PEP was 7% in stent group and 5% in non-stent group (NS; p=0.83). In 3 cases (4%) of stent group, stent retention in CBD was observed, which was successfully removed endoscopically. No other severe adverse event such as perforation of retained stent was observed. Temporary biliary stents are suggested to have preventive effects of post-ERCP cholangitis and shorten hospitalization.

Troubleshooting for severe acute cholangitis caused by proximally migrated metal stent into the intrahepatic bile duct: Stent shortening via a balloon catheter.

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Results of surgical treatment of extrahepatic bile duct injuries

Aim. To evaluate the short-and long-term outcomes after surgical repair of iatrogenic lesions of extrahepatic bile ducts depending on the timing of diagnosis in conditions of specialized clinic.&#x0D; Materials and methods. Our study involved a retrospective analysis of 159 patients who were treated for iatrogenic lesions of extrahepatic bile ducts during 1987-2017. These patients were divided into two groups depending on the timing of surgical treatments: early biliary reconstruction ( 5 days after bile duct transection) and late biliary reconstruction ( 5 days post-transection). These groups were compared on the basis of postoperative morbidity and long-term outcomes.&#x0D; Results. Following laparoscopic cholecystectomy, 2 patients received endoscopic retrograde stents due to bile leakage from the cystic ducts, and 14 patients underwent hepaticocholedochostomy using Ker drainage. The incidence of bile leakage was observed in 14. 3 % of cases during the early post-operative period, strictures appeared in 28.6 % of cases. Hepaticojejunostomy was performed in 91 cases: in 62 with stents and in 29 without stents. Bile leakage was observed in 17.6 % of cases, and strictures in 19.8 % of cases. Our statistical analyses revealed no significant differences between the two groups (i.e., early and late timing of surgical treatment) in the rates of bile leakage and strictures. The extent of surgeons experience in bile surgery significantly correlated with positive outcomes.&#x0D; Conclusions. Endoscopic retrograde stent proved to be an effective and fast solution in cases of bile leakage from cystic ducts following laparoscopic cholecystectomy. Although it is preferable to perform reconstructive surgeries within the first five days after bile duct injury, our results indicated that in the presence of external bile fistula without peritonitis and severe cholangitis, reconstructive surgery can be performed in specialized surgical departments later than 5 days with satisfactory results.

Smooth Muscle Distribution Patterns of Choledochal Cysts and Their Implications for Pathogenesis and Postoperative Complications.

Histopathologic characteristics of choledochal cysts and their clinical implications have not been previously comprehensively studied. Smooth muscle distribution patterns and other histologic findings (inflammation, metaplasia, dysplasia, and heterotopia) in 233 surgically resected choledochal cysts were evaluated. Mean patient age was 23.3 ± 19.8 years, with male:female ratio of 0.3. Most cases were Todani type I (175 cases, 75.1%) or IVa (56 cases, 24.1%). Choledochal cysts with thin scattered/no muscle fiber (175 cases, 75.1%) were the predominant pattern and were associated with more frequent postoperative biliary stricture (P = .031), less frequent pyloric metaplasia (P = .016), and mucosal smooth muscle aggregates (P < .001) compared to cysts with thick muscle bundles. Severe chronic cholangitis (P = .049), pyloric metaplasia (P = .019), mucosal smooth muscle aggregates (P < .001), biliary intraepithelial neoplasia (P = .021), and associated bile duct (P = .021) and gallbladder carcinomas (P = .03) were more common in adults (age >20 years vs ≤20 years), suggesting that chronic irritation in association with developmental anomalies involves tumorigenesis from choledochal cysts. Smooth muscle distribution pattern of choledochal cyst may predict postoperative complication, raising clinical implications of smooth muscle patterns in postoperative management of choledochal cysts.

What Is the Role of Endoscopic Retrograde Cholangio-Pancreato-Grahy in the Management of Hepatic Hydatid Disease Complications?

Liver hydatid cyst is a parasitic disease that is endemic in Morocco. Its gravity is essentially due to its complications, such as Intrabiliary rupture. The aim of our study was to evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy in the management of intrabiliary rupture of hydatid disease of the liver. Materials and Methods: This is a retrospective study in the department of Gastroenterology in the University Hospital Hassan II of Fez over a period of 12 years from March 2005 to October 2017. All patients admitted for hepatic hydatid disease and who received ERCP were included. We analyzed the success rate of catheterization of the common bile duct (CBD), the successful clearance of the bile duct and the complications. Results: 2860 patients had received therapeutic ERCP, 151 patients (5.3%) had hepatic hydatid disease, 112 of which had intrabiliary disruption of hepatic hydatid and 39 patients were admitted for sphincteromy for reversal of the flow after surgery of hydatid cyst. The average age of our patients was 41 years old [12 - 85]. The sex ratio F/H = was 1.12. 74% (N = 112) patients were admitted to a table cholangitis and 26% of cases were operated for KHF fistulized in the bile ducts with persistence of a large biliary flow in post-operative (39 cases). The success of initial catheterization of the commun bile duct was achieved for 138 patients (91%) or obtained secondarily after precut for 13 patients. The evacuation of hydatid membranes was carried out in 51% of them (N = 78); twenty two (14.5%) patients had one or more calculations with or without hydatid membranes. A case of gastrointestinal bleeding post ERCP was observed. All the patients followed evolved well in the long term except for two patients who presented in few months after the first ERCP severe cholangitis which required the use of a second ERCP with successful evacuation of membranes. Conclusion: In our study, endoscopic management of hydatid cyst remains a dominant position, with a very satisfactory success rate and an acceptable rate of morbidity and mortality.

The risk of acute cholangitis after endoscopic stenting for malignant hilar strictures: A large comprehensive study.

Endoscopic stenting for unresectable malignant hilar biliary strictures (MHBS) remains challenging. Post-endoscopic retrograde cholangiopancreatography cholangitis (PEC) can be the most common and fatal adverse event. In the present study, we aimed to systematically evaluate the incidence, severity, risk factors, and consequences of PEC after endoscopic procedures for advanced MHBS. Of 924 patients, we identified 502 patients with MHBS (Bismuth types II to IV) who underwent endoscopic stenting as the primary therapy at two centers over 16years. PEC and its severity were verified according to the current Tokyo guidelines. A total of 108 patients (21.5%) experienced acute PEC. Mild, moderate, and severe cholangitis were encountered in 51 (10.1%), 42 (8.4%), and 15 (3.0%) patients, respectively. Multivariate analyses showed that metal stenting (verse plastic stenting) (OR 0.328, 95% CI 0.200-0.535, P<0.001) and Bismuth classification (IV vs III/II) (OR 2.499, 95% CI 1.150-5.430) were independent predictors for PEC and the moderate/severe type. Patients with PEC had significantly lower clinical success rates (86.3% vs 41.7%, P<0.001), a higher rate of early death (6.5% vs 0.5%, P<0.001), a shorter median stent patency (4.9 vs 6.4months, P<0.001), and shorter overall survival (2.6 vs 5.2months, P<0.001) compared with the noncholangitis group. After endoscopic stenting for advanced MHBS, cholangitis may occur in as many as 21.5% of patients, which may be associated with a poor prognosis. The risk is high in patients with Bismuth type IV and may be reduced by using metal stents.

Is Short Antibiotherapy Duration After Drainage Suitable for Patients Admitted in Intensive Care Medicine With a Severe Acute Cholangitis?

Is Short Antibiotherapy Duration After Drainage Suitable for Patients Admitted in Intensive Care Medicine With a Severe Acute Cholangitis?

1424 Follicular Cholangitis Presenting as Cholangiocarcinoma in a Patient With Serologic Evidence of Autoimmune Disease

INTRODUCTION: Follicular cholangitis is a rare sclerosing cholangitis of the biliary hilum that is difficult to distinguish from primary sclerosing cholangitis, immunoglobulin G4-related sclerosing cholangitis, and most imperatively, hilar cholangiocarcinoma. Pathological findings include fibrotic thickening of bile duct walls containing lymph follicles with germinal center formation. While autoimmune evaluations have previously been negative, we herein report the first case of follicular cholangitis found in the pretense of autoimmune hepatitis. CASE DESCRIPTION/METHODS: A 40-year-old female presented following a 2-month history of pruritis, fatigue, and elevation of hepatobiliary enzymes (AST 113 U/L, ALT132 U/L, ALP 499 U/L). Medical history was significant for cholestasis of pregnancy 10 years ago. Laboratory evaluation was positive for an ANA (1:160), an atypical pANCA (1:320), and an elevated F-actin (101 units) while negative for anti-mitochondrial antibody. Serum IgG levels were normal (1250 mg/dl; IgG4 subclass &lt;1). IgM level was elevated at 350 mg/dl. Liver biopsy showed dense portal lymphatic inflammation, including focal germinal center formation as well as paucity of bile ducts without florid ductal lesion or fibrosis. Initial treatment with glucocorticoids, azathioprine and ursodiol did not improve symptoms or liver chemistries. ERCP revealed a tight stricture with direct visualization (spyglass) of a biliary lesion in the distal third of the common bile duct (CBD). Cytology from the stricture returned atypical cells suspicious for adenocarcinoma. Bile duct biopsy revealed severe chronic inflammation and few atypical glands. IgG4 immunostaining was negative. She underwent pancreaticoduodenectomy due to concern for cholangiocarcinoma. Macroscopically, the CBD mucosa was diffusely granular and without mass lesions. Microscopically; bile duct fibrosis, lymphoid hyperplasia with prominent germinal centers, and rare IgG4-positive cells were consistent with severe follicular cholangitis. DISCUSSION: Unique to this case is the serological backdrop and histologic findings of autoimmune disease. Whereas previous cases have been strictly ANA negative, there appears to be an unexplored continuum of disease as evidenced by cases of follicular bronchiolitis which have been associated with autoimmune disease and have similar immunohistologic findings. Although the etiology remains unclear, the existence of an autoimmune association raises important considerations for medical therapies.

52 Decline in Total Serum Bilirubin Level Is Sensitive but Not Specific Marker for Spontaneous Common Bile Duct Stones Passage

INTRODUCTION: Increased serum total bilirubin (T. bili: mg/dl) on presentation is one of the commonly used markers for the presence of common bile duct (CBD) stones. We sought to examine the relationship between the decrease in T. bili level and the probability of spontaneous stone passage in patients (pts) with suspected or confirmed choledocholithiasis. METHODS: Pts who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) used in pts with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least 3 measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following confirmatory studies: MRCP, ERCP, EUS or IOC. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Regression analysis was performed to identify independent variables associated with retained stone despite consistent decline in T. bili level. RESULTS: 825 pts were identified according to the screening criteria. 723 pts were excluded due to having pathologies and 102 pts were included in this study (48 males &amp; 54 females). Mean age of 57.4 years ± 22. 33 pts had fluctuation or no decline in T. bili level and 30 of them (92%) were confirmed to have retained stones. Among the 75 pts with consistent decline in T. bili level after 48 hours from initial presentation, 26 (34.7%) were found to have retained stone while 49 (65.3%) were confirmed to have no retained stones (passed spontaneously). On regression analysis, predictors of the presence of retained CBD stone(s) despite consistent decline in T. bili level included: pts older than 55 (OR 1.9; 95% CI: 1.1, 3.4) and pts presented with severe cholangitis defined as WBC &gt; 16,000 and hypotension (OR 1.6; 95% CI 1.2–2.7). CONCLUSION: Although consistent decline in T. bili level is a sensitive predictor for spontaneous CBD stone passage, it is not specific and can be seen in at least one third of patients with documented retained stones. Possible explanations for decreased specificity include vigorous medical support (hydration &amp; antibiotics) that may contribute to decline in T. bili level even in the setting of retained stones.

Checkpoint inhibitor-induced liver injury: A novel form of liver disease emerging in the era of cancer immunotherapy.

Liver injury triggered by immune checkpoint inhibitors has been increasingly seen in clinical practice, and the incidence is likely to rise further in the next several years because of expanded indications for cancer immunotherapy. Tissue damage driven by disrupted immune tolerance against self-antigens is called an immune-related adverse event (irAE). irAEs in the liver histologically presents panlobular hepatitis (∼70%), isolated central zonal necrosis (∼20%), primarily granulomatous hepatitis (∼5%), and other minor forms of tissue injury (∼5%). Infiltrating cells are mainly lymphocytes and occasional eosinophils. Unlike classic autoimmune hepatitis (AIH), plasma cell infiltration is not conspicuous. Immunostaining reveals a large number of CD8+ T lymphocytes and a markedly smaller number of CD4+ cells or CD20+ B lymphocytes. The unique CD3+/CD20+ and CD4+/CD8+ ratios shifted in favor of CD8+ cytotoxic T lymphocytes are helpful to discriminate irAEs from other conditions (e.g., AIH, idiosyncratic drug-induced liver injury). Another hepatobiliary manifestation of irAEs is sclerosing cholangitis clinically characterized by elevations of biliary enzymes, diffuse duct wall thickening, and duct dilatation. Lymphocytic infiltration can be observed by endoscopic biopsies from the thick extrahepatic bile ducts, and liver needle biopsies may also show severe lymphocytic cholangitis resembling primary biliary cholangitis. An important differential diagnosis of irAEs is previously asymptomatic or subclinical liver disease unmasked by cancer immunotherapy, which is often challenging and requires close clinicopathological correlations.

Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis.

AIMTo assess the effect of early vs late endoscopic retrograde cholangiopancreatography (ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODSWe used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day (days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure, acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with in-hospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex, severe disease and comorbidities.RESULTSFour thousand five hundred and seventy patients satisfied the inclusion criteria; with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs 2.4%, adjusted odds ratio (aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality (1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions (9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group (6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group ($21459 vs $16939, P < 0.0001).CONCLUSIONEarly ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.

Liver transplantation after complete hepatic artery avulsion secondary to blunt abdominal trauma

Background: Hepatic artery avulsion secondary to blunt abdominal trauma is a rare cause of massive hemoperitoneum. Ischemic cholangiopathy it is a possible complication secondary to its ligation. Methods: We report the case of a trauma patient with ischemic cholangiopathy secondary to hepatic artery ligation who required liver transplant (LT). Results: A 37-year-old man was admitted to the emergency room after falling from a third-floor flat. During surgical exploration, a massive hemoperitoneum secondary to hepatic artery avulsion was observed. Reconstruction of the artery could not be achieved so it was ligated. He was admitted to ICU, improving progressively of his hemodynamic instability and ischemic hepatic failure. MRI, 34 days after surgery, showed diffuse ischemic cholangiopathy. After severe repeated cholangitis he was included for LT that was performed 70 days after surgery using a classic technique due to its huge liver volume (4200 gr). During immediate postoperative period he was reoperated four times due to hemoperitoneum and necrohemorrhagic pancreatitis. On day 36th after LT, he developed a nonsurgical intracranial hemorrhage, dying 2 days after. Conclusion: Diffuse ischemic cholangiopathy secondary to hepatic artery lesion is an uncommon indication of LT. Traumatized patients with vascular lesions should be transferred to a specialized center.

Melioidosis presented as severe acute cholangitis: A rare presentation

Introduction: Melioidosis is caused by a Gramnegative bacteria known as Burkholderia pseudomallei. Clinical manifestation of the disease is unspecific, leading to wrong diagnosis and delayed in administration of appropriate antibiotics. Case Report: This case reported an atypical presentation of melioidosis in a 45-year-old Malay lady with underlying asthma and hypertension who presented with generalized abdominal pain for 14 days. A few days before admission she developed high grade fever and jaundice. She was initially treated as ascending cholangitis. The diagnosis was changed to disseminated melioidosis after computed tomography (CT) scan findings and isolation of B. pseudomallei from the blood culture. She was treated with antibiotics according to the melioidosis regime and responded well to the therapy. Conclusion: Acute cholangitis or cholecystitis is a rare presentation of melioidosis. High degree of suspicion is very crucial in a patient presented with any severe illness especially in an endemic area.

Secondary Multiple Choledocholithiasis in Obstructive Jaundice Patient Due to Choledochoduodenal-Fistula Stricture

Introduction Choledochoduodenal fistula is a rare condition in which an abnormal connection between the biliary duct and duodenum. The causes of choledochoduodenal fistula are cholelithiasis, pancreatobiliary tumor, and less common by duodenal ulcer. Fistula is advantageous as an alternate way of biliary drainage when the main biliary duct is obstructed. Case Illustration A 43 years old female, admitted with acute severe cholangitis. Patient was undergone cholecystectomy 3 years ago. Ultrasound and MRCP revealed biliary stone with dilatation of intra and extra hepatic biliary ducts. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a fistula between bile duct and duodenum with stricture at distal part of fistula toward the duodenum, multiple biliary stone in the bile duct, and total obstruction at ampulla of Vater. The stricture at distal fistula made secondary-choledocholithiasis then lead to severe cholangitis, whereas the distal part of bile duct toward the duodenum was totally obstructed. Cannulation at fistula was performed, followed by inserting a plastic stent for urgent temporary bile-drainage. Subsequently, patient improved clinically. The plastic stent was changed by fully-covered self-expanding metal stent (SEMS) 3 days afterward. Six weeks later on follow up, after SEMS removal cholangiogram was obtained showing no stones in the bile duct. The bile concurrent with biliary stones passed spontaneously through the fistula while SEMS was in placed. Therefore, the patient did not require surgery intervention to remove biliary stones. Conclusion This case demonstrated a secondary choledocholithiasis in obstructive jaundice patient with acute severe cholangitis due to the choledochoduodenal fistula stricture. Inserting self-expandable stent in the fistula allows both bile and even biliary stone to pass spontaneously. This stent insertion may serve as an alternative practice to avoid surgery procedures on biliary drainage and removing biliary stones, in choledochoduodenal fistula cases.2162_A Figure 1. Multiple choledocholithiasis2162_B Figure 2. Self-Expanding Metal Stent (SEMS) insertion2162_C Figure 3. Post SEMS removal

Procalcitonin levels at admission as a predictor of coexisting acute moderate and severe cholangitis in acute pancreatitis

Background: It is clinically and analytically challenging to determine when acute pancreatitis (AP) overlaps with acute cholangitis (AC) in an emergency setting. Starting wide spectrum antibiotics, ordering endoscopic retrograde cholangiopancreatography or CT scans depends upon accurate diagnosis. The aim of our study is to determine whether procalcitonin levels greater or equal than 2ng/ml could differentiate and predict moderate and severe acute cholangitis in AP patients. Methods: Clinical data of 57 AP patients, prospectively enrolled for study at our institution were analyzed. PCT, PCR levels were dosed during the first 72 hours since symptomatic onset as well as the APACHE-II index and C-reactive protein > 15mg/dl. Moderate and severe acute cholangitis (AC) was reported according Tokyo Criteria 2013 (TG13). In order to determine statistical significance, Pearson´s chi-squared test was used. For determining PCT prediction, area-under-the-curve receiver-operating characteristics (AUC) were applied. Results: Moderate and Severe AC was higher in PCT levels>2ng/ml group (45.5% vs. 2.2%, p= 0.). PCT levels ≥ 2ng/ml outperformed CRP>15mg/dl and APACHE-II for moderate and severe AC prediction with a significant accuracy (AUC 0.804, CI 0.63-1, p=0.013). Conclusion: PCT levels at admission could help rule out and predict concomitant acute pancreatitis and moderate-severe acute cholangitis.