Treatment Of Acute Cholangitis Research Articles

Validation of the Tokyo Guidelines for the Management of Acute Cholangitis from Benign and Malignant Obstruction

Purpose: The Tokyo guidelines were proposed in 2007 to define uniform, evidence-based criteria for the diagnosis, severity assessment, and treatment of acute cholangitis (AC). Its utility for the diagnosis and management of AC secondary to malignant obstruction has not been validated. Our aims include assessment of the diagnostic accuracy, rate of adherence to treatment strategy, and impact of the Tokyo guidelines on clinical outcomes in patients with benign and malignant obstruction. Methods: We retrospectively reviewed all patients who underwent endoscopic biliary drainage for AC at a Chinese national referral center from 2001 to 2009. We included patients who fulfilled the following clinical, endoscopic, and laboratory parameters: detection of purulent bile or pus during endoscopic biliary drainage, presence of fever or chills, leukocytosis or elevated C-reactive protein in the setting of cholangitis. Descriptive statistics and univariate analyses were conducted to compare clinical parameters and outcomes of patients with benign and malignant obstruction in relation to the Tokyo guidelines. Results: There were 120 patients of which 82 (68.3%) had benign disease and 38 (31.6%) with malignant obstruction. The demographic characteristics include: mean age 66 ± 15 y.o., 85 (69.1%) males. Charcot's triad was present in only 61 (50.8%) patients as compared to 104 (86.7%) patients who fulfilled the Tokyo diagnostic criteria for definitive AC (p<0.0001). The diagnostic accuracy of the Tokyo guidelines were 82.9% and 94.7% for benign and malignant obstruction, respectively (p=0.05). There were 58 (70.7%) patients with benign obstruction who underwent endoscopic drainage compared to 15 (39.5%) patients with malignant obstructive etiology treated consistently with the Tokyo guidelines (p=0.001). The difference in adherence was predominately observed in patients with AC of moderate severity. In comparing patients who received treatment consistent with or independent from the Tokyo guidelines, we found no significant difference in their clinical outcomes in terms of: length of hospital stay, incidence of repeated endoscopic treatment, success rate of endoscopic drainage, incidence of complications, and early death within 30 days of admission; regardless of benign or malignant obstructive etiology. Conclusion: The Tokyo guidelines can be a reliable tool for the diagnosis of AC for both benign and malignant obstruction. It is superior over the clinical criteria of Charcot's triad. Patients with benign obstruction are more likely to receive endoscopic biliary drainage consistent with the Tokyo guidelines. However, there was no effect on the clinical outcomes in adherence with the Tokyo guidelines for the management of AC.

Bile bacterial flora and its in vitro resistance pattern in patients with acute cholangitis resulting from choledocholithiasis

Introduction. Cholangitis and biliary sepsis are severe infectious diseases, which are often observed in patients with choledocholithiasis. The antimicrobial therapy is effective if started as soon as the diagnosis is made. Therefore, the profile of bile pathogens and its susceptibility to a number of antibiotics were evaluated. Material and methods. Bile cultures and antibiograms from 92 patients hospitalized between January 2006 and December 2008 in a tertiary referral center for the treatment of biliary and pancreatic diseases (Central Teaching Hospital, Medical University of Silesia) were reviewed. Specimens were obtained from patients with acute cholangitis and confirmed choledocholithiasis during endoscopic (i.e. ERCP) and surgical (i.e. percutaneus transhepatic biliary drainage) procedures. The bile specimens were examined for pathogenic aerobic and anaerobic bacteria and fungi. Results. Sixty-five of 92 analyzed cultures were positive. A total of 69 pathogens were isolated: 47 (68.1%) Gram-negative bacteria, 18 (26.1%) Gram-positive bacteria, 2 (2.9%) anaerobes and 2 (2.9%) Candida. The predominant Gram-negative pathogens were Escherichia coli, Acinetobacter baumani complex, Klebsiella pneumoniae and Enterobacter cloacae. The most effective antibiotics against Gram-negative bacteria were imipenem, cefoperazone/sulbactam, piperacillin/tazobactam and cefepime (susceptibility 97.9%, 89.4%, 85.1% and 85.1%, respectively). The expenditure on antibiotics monotherapies and combined therapies was also analyzed. Conclusion. Our study shows that Gram-negative bacteria were the predominant bile pathogens found in patients with acute cholangitis. Piperacillin/tazobactam or ceftazidime may be the alternative to ciprofloxacin therapeutic option. The addition of ticarcillin/clavulanic acid to ciprofloxacin could also be considered. However, imipenem should remain a back-up antibiotic in the treatment of acute cholangitis.

Sa1515 Efficacy of Wire-Guided Cannulation of the Bile Duct in the Treatment of Acute Cholangitis

Rapid biliary decompression is important in the treatment of acute cholangitis. Because of nonuse of contrast medium injection, wire-guided cannulation (WGC) is considered to avoid enlarging intrabiliary pressure. WGC during endoscopic biliary drainage might reduce the duration of acute cholangitis compared to standard cannulation (SC). We retrospectively analyzed patients with acute cholangitis underwent urgent biliary drainage using WGC or SC successfully. Patients with normal body temperature, acute pancreatitis, hepatic abscess, hilar biliary obstruction, and biliary metallic stent, whose distal end was in the duodenum, were excluded. The duration of fever, the time of procedure, and complications were compared between both cannulation methods. The timing of injection of contrast medium was: after fully aspiration of bile juice in WGC, before aspiration in SC. Severity of cholangitis was based on Tokyo Guideline. Either endoscopic nasobiliary drainage (ENBD) tube or plastic stent (PS) was used as drainage device. Eighty-three patients (32 in WGC, 51 in SC) were eligible between April 2007 and April 2010. The baseline characteristics did not show significant differences in following parameters: median age, 77y vs. 76y; male, 66% vs. 49%; causative diseases (common bile duct stone, 25 vs. 40; cholangiocarcinoma, 4 vs. 6; pancreatic cancer, 2 vs. 3; hepatocellular carcinoma, 1 vs. 1; and chronic pancreatitis, 0 vs. 1); severity (mild, 7 vs. 8; moderate, 19 vs. 27; and severe, 6 vs. 16); and diabetes mellitus, 8 vs. 10. There was significant difference in ASA score (1/2/3/4, 2/17/13/0 vs. 10/32/8/1, P = 0.03). There was no significant differences in drainage devices (ENBD/PS, 28/4 vs. 46/5). The duration of fever was significantly shorter in WGC than SC (1 day [interquartile range, 1-2.75] vs. 2 days [2-4], P = 0.01). The median time of procedure (16.5min. vs. 25min.), post-ERCP pancreatitis (0% vs. 5.9%), and hyperamylasemia (15.6% vs. 21.6%) were not significantly different, but WGC exceeded SC in all these subjects. Subset analysis of the duration of fever according to severity revealed significant difference in severe group (1 [1-4] vs. 3.5 [2-4.75], P = 0.048), but no significant difference in mild (2 [1-3] vs. 1.5 [1-2.75]) and moderate group (1 [1-2] vs. 2 [1-3]). WGC during endoscopic biliary drainage reduced the duration of acute cholangitis compared to SC, especially in severe cases.

Treatment of acute cholangitis with hepatolithiasis.

To evaluate the treatment of recurrent acute cholangitis with hepatolithiasis. We retrospectively analyzed the clinical data of patients with recurrent acute cholangitis who were treated in Peking Union Medical College Hospitals emergency department from January 1998 to December 2008. Totally 408 patients underwent surgery, of which 167 patients received emergency operations and 241 underwent selective operations after medication and interventional treatment. The incidence of complications was 6.4% among those who received emergency operations and 3.2% among selective operations. The 30-day mortality rate of selective operations was zero. Along with the progress of percutaneous cholangiographic drainage and endoscopic retrograde cholangiopancreatography, selective operations have been increasingly applied for acute cholangitis with notably low complications and postoperative death.

Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines

The Tokyo Guidelines formulate clinical guidance for healthcare providers regarding the diagnosis, severity assessment, and treatment of acute cholangitis and acute cholecystitis. The Guidelines were developed through a comprehensive literature search and selection of evidence. Recommendations were based on the strength and quality of evidence. Expert consensus opinion was used to enhance or formulate important areas where data were insufficient. A working group, composed of gastroenterologists and surgeons with expertise in biliary tract surgery, supplemented with physicians in critical care medicine, epidemiology, and laboratory medicine, was selected to formulate draft guidelines. Several other groups (including members of the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary-Pancreatic Surgery) have reviewed and revised the draft guidelines. To build a global consensus on the management of acute biliary infection, an international expert panel, representing experts in this area, was established. Between April 1 and 2, 2006, an International Consensus Meeting on acute biliary infections was held in Tokyo. A consensus was determined based on best available scientific evidence and discussion by the panel of experts. This report describes the highlights of the Tokyo International Consensus Meeting in 2006. Some important areas focused on at the meeting include proposals for internationally accepted diagnostic criteria and severity assessment for both clinical and research purposes.

Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines

Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment, and their condition has not improved. Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous transhepatic, and open methods. The clinical value of both endoscopic and percutaneous transhepatic drainage is well known. Endoscopic drainage is associated with a low morbidity rate and shorter duration of hospitalization; therefore, this approach is advocated whenever it is applicable. In endoscopic drainage, either endoscopic nasobiliary drainage (ENBD) or tube stent placement can be used. There is no significant difference in the success rate, effectiveness, and morbidity between the two procedures. The decision to perform endoscopic sphincterotomy (EST) is made based on the patient’s condition and the number and diameter of common bile duct stones. Open drainage, on the other hand, should be applied only in patients for whom endoscopic or percutaneous transhepatic drainage is contraindicated or has not been successfully performed. Cholecystectomy is recommended in patients with gallbladder stones, following the resolution of acute cholangitis with medical treatment, unless the patient has poor operative risk factors or declines surgery.

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.

Endoscopic Management Strategies in Relation to the Severity of Acute Cholangitis

Acute cholangitis (AC) and especially suppurative cholangitis due to biliary lithiasis is an emergency situation that requires urgent biliary decompression. The aim of the study is to present our policy for the treatment of AC due to choledocholithiasis, endoscopically. In a 4-year period, 71 patients presenting AC, due to lithiasis, underwent endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy (ES). All patients had fever, jaundice, abdominal pain, and in case of suppurative cholangitis hemodynamic instability. Most of them seemed to be high-risk candidates for surgery. Forty-nine patients had AC and 22 patients had acute obstructive suppurative cholangitis (AOSC). ES (conventional or needle-knife biliary fistulotomy) was successful in 69 out of 71 (97%) patients. Two patients were eventually operated and were excluded from statistical analysis. Fifty of the 69 patients (72%) had a complete bile duct clearance in 1 session. Conventional ES, complete bile duct clearance, and other endoscopic maneuvers (balloon, basket, lithotripsy) were significantly more frequent in the AC group (P<0.001). Needle-knife biliary fistulotomy, and stent insertion were significantly more frequent in the AOSC group (P<0.001). Endoscopical treatment had low morbidity and total hospital stay time. ES is the procedure of choice for the treatment of AC offering definite treatment with low morbidity and short hospitalization. Urgent biliary decompression with minimal endoscopic maneuvers is crucial for the outcome of patients having AOSC.

Impact of antipyretic and purgative herbs on intestinal mucosal barrier and inflammatory response in treatment of acute cholangitis in rats

To investigate the effects of antipyretic and purgative herbs on intestinal mucosal barrier and inflammatory response in the treatment of acute cholangitis. Sixty SD rats were randomly divided into group A (untreated group, acute cholangitis was induced, n=20), group B (treatment group, acute cholangitis was induced and treated with antipyretic and purgative herbs, n=20) and group C (sham operation group, n=20). At the third or fifth day after operation, the rats were sacrificed and sampled. The serum endotoxin, cytokines and inflammatory mediators were tested and the numbers of labeled bacteria in the liver, spleen and mesenteric lymph nodes translocated from the gut were assayed. As compared with group A, the serum content of endotoxin, IL-6, IL-8, TNF-alpha, CRP and NO was significantly lower and that of IL-2 was significantly higher, and the translocated numbers of labeled bacteria from gut were reduced in both group B and group C (P<0.01). Antipyretic and purgative herbs can play therapeutic roles in the treatment of acute biliary tract infections, including the protection of intestinal mucosal barrier from bacterial translocation, reduction of serum endotoxin content and regulation of inflammatory response.

Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones

Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones Neven Ljubicic, Luka Rotkvic Background: It has been shown that urgent endoscopic drainage is an effective treatment for acute cholangitis and is superior to surgical drainage with a better clinical outcome Because of the risk of post-sphincterotomy bleeding in these patients many endoscopists have advocated endoscopic drainage by using nasobiliary catheter or an indwelling stent without sphincterotomy. The aim of this study was to analyze safety and efficacy of endoscopic sphincterotomy (ES) and urgent stone extraction in patients with acute cholangitis due to the common bile duct stones.Methods: Between January andDecember 2002, one hundred and eleven patients with clinical jaundice and common bile duct stones were enrolled to an ES and urgent stone extraction. ES has been performed in a standard manner, always using the guide-wire. In patients with cholangitis vigorous washing of the common bile duct has been performed after removal of the stones. Forty-six patients fulfilled criteria for acute cholangitis. Prior to the ES all patients received intravenously ciprofloxacin for at least 24 hours. Results: ES has been performed successfully in 102 (92%) patients. Complete duct clearance has been achieved in 90% of patients without cholangitis and in 93% of patients with cholangitis (not significant). Complications occurred in 12% of patients without and in 16% of those with acute cholangitis (Table). In patients with post-sphincterotomy bleeding blood transfusion was not required. The median lengths of time for resolution of jaundice in patients with and without cholangitis were similar. Significant coagulopathy has been observed in two (4.5%) patients with acute cholangitis. In those patients there were no bleeding occurred after ES. Conclusions: ES and bile duct clearance is very effective and safe method even in the patients with acute cholangitis. Mild bleeding was the most common postsphincterotomy complication not required blood transfusion even in the presence of coagulopathy. *T1500 MRCP Vs ERCP: A Comparative Study in Diagnosis of Common Bile Duct Stones Luigi T. Familiari Background: Because it is a noninvasive method, without complications, the magnetic resonance cholangiography (MRCP) is going to reliably replace ERCP in the diagnosis of pancreato-biliary diseases. Althoughmany studies documented a high sensitivity and specificity of MRCP, its ability in detecting microlithiasis ( 270; I-GT > 50 UI/l). Patients underwent upper abdominal ultrasonography (US), thenMRCP and, within 72 h, diagnostic and/or operative ERCP. All patients signed an informed consent. The statistical analysis was based on the report of true positives and negatives, false positives and negatives. Results:106/123 patients completed the study. MRCP diagnosed lithiasis of CBD in 73; did not document stones in 33. ERCP confirmed the presence of lithiasis in 66/73 pts who were submitted to ES. Seven were not found to have stones after ES.Among 33 negative pts, ERCPdocumented stones in 9: in 4 only after ES (it was performed according to clinico-biochemical data and to CBD dilation, though ERCP did not identify stones). The stones were 2-3 mm. In 24/33 patients negative at MRCP, ERCP confirmed this response:10/24 were submitted to ES. ES was not performed in 14/24 subjects, without CBD dilation and/or cholestasis. After a 27.8 months follow-up (range: 4-54), 8/14 remained asymptomatic, 6 underwent laparoscopic cholecystectomy without finding of CBD stones at the intra-operative cholangiography. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 77%, 85%, 90%, 73%. Conclusions: asMRCPhas still a limitation in the diagnosis of small stones,missed at US, it leaves unrisolved the question of which patient is candidate to ERCP/ES. The recognition of microlithiasis should refer to other imaging techniques preliminar to ERCP (e.g. EUS) though their limited availability makes until now MRCP a method of choice in the diagnosis of biliary disease.

Colangitis aguda debida a coledocolitiasis:¿Cirugía tradicional o drenaje biliar endoscópico?

Endoscopic drainage of the biliary tree for acute cholangitis is a therapeutic modality with a lower mortality and complication rates.To compare endoscopic drainage with surgical treatment in the emergency management of acute cholangitis.Between 1995 and 1998, sixty five patients with acute cholangitis were subjected to an endoscopic drainage of the biliary tree. In the same period, 40 patients were treated with traditional surgical procedures. The evolution of both groups of patients were compared.Sixty two patients (95.4%) subjected to endoscopic treatment had a satisfactory evolution, compared with 23 (58%) of those operated (p < 0.001). Five operated patients and no individual subjected to endoscopic drainage died (p < 0.01). Mean postoperative hospital stay of operated patients was 15.5 +/- 19.6 days compared to 5.8 +/- 4.2 days in those subjected to endoscopic drainage (p < 0.001). Definitive resolution of biliary obstruction was achieved in 83% of patients subjected to endoscopic drainage or traditional surgery.Endoscopic drainage has a lower rate of complications and mortality than traditional surgery, in the treatment of acute cholangitis.

The Transduodenal Endoscopic Treatment of Acute Cholangitis

Abstract:Mortality due to acute cholangitis (AC) has been tremendously reduced by the advent of endoscopic sphincterotomy (EST). This study investigates whether EST is really a curative procedure for the treatment of AC, or not. Diagnosis of AC, in 159 out of 1,061 cases in which EST was performed, had been made by infected bile which was recognized as green or pyobile collected during ERCP. Emergency drainage by EST was performed immediately after AC was diagnosed. The causes of AC were attributable to benign diseases in 128 cases (80.5%) and malignant diseases in the remaining 31 cases. Clinical symptoms included abdominal pain, fever, and obstructive jaundice, but Charcot's triad was noticed in 66 cases (43.3%) and Reynolds pentad in only 7 cases (4.6%). As to the relation between clinical symptoms and properties of bile, pyobile was more likely to be recognized in patients with severe symptoms.Four patients treated at our hospital died of AC (2.5%). All were over 80 years old, and their conditions were already complicated by disseminating intravascular coagulation (DIC) syndrome. Compared with the results obtained in patients treated with percutaneous transhepatic biliary drainage (PTBD), the resulting mortality rate was less. Therefore, we feel the best approach for treating AC, which progresses to acute obstructive suppurative cholangitis (AOSC) in the final stage of the disease, is to diagnose early, by ERCP, and to promptly obtain decompression by subsequent EST, or to perform radical surgery.

The treatment of acute cholangitis. Percutaneous transhepatic biliary drainage before definitive therapy.

Forty-two patients with acute cholangitis, as evidenced by fever (95%), jaundice (86%), and right upper quadrant pain (67%), were treated with fluid and electrolyte resuscitation, broad spectrum antibiotic coverage, and initial percutaneous transhepatic biliary drainage (PTD). Despite a 17% incidence of nondilated ductal systems, drainage was established in all patients using a 22-gauge "skinny" needle and "accordion" catheter. No attempt was made at definitive cholangiogram; only 1-2 mL of contrast were injected to confirm placement of the catheter. Sepsis began to resolve in all patients within 24 hours of PTD, after which definitive cholangiogram was performed. PTD was accompanied by a 7% (3/42) complication rate, none of which contributed to subsequent morbidity and mortality. Two patients in severe septic shock had PTD but died within 8 hours of admission, constituting a 5% mortality rate. Definitive therapy after resolution of sepsis included: surgical (16 patients), internal/external drainage (14 patients), balloon dilatation (10 patients), mono-octanoin infusion (1 patient), and ampullary dilatation (1 patient). The surgical morbidity rate was 18%. There was no mortality. PTD is effective in providing decompression as initial therapy for acute cholangitis with minimal morbidity. Accurate diagnosis provided by the definitive cholangiogram obviates the need for multiple surgical procedures. PTD provides a portal to the biliary tract for alternative procedures (i.e., internal/external drainage, balloon dilatation), especially in patients with medical contraindications to surgery.