LA CONSULTA SEMANAL

 

OCTUBRE 2000

 

 

CONSULTA

Colangitis

 

Gastrointest Endosc 2000 Oct;52(4):484-9

Effectiveness of ERCP in cholangitis: A community-based study.

Chak A, Cooper GS, Lloyd LE, Hammar PJ, Issa K, Rosenthal GE

Divisions of Gastroenterology, University Hospitals of Cleveland and MetroHealth Medical Center, Case Western Reserve University; and Quality Information Management Corporation, Cleveland, Ohio.

BACKGROUND: Although experts have demonstrated the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in cholangitis, the effectiveness of ERCP in unselected patients has not been measured. The aim was to investigate the clinical impact of ERCP performed at any time and of early ERCP (within 24 hours of admission) in patients with a primary discharge diagnosis of cholangitis. METHODS: A retrospective record review of patients admitted to eight area hospitals with an International Classification of Diseases (ICD)-9 diagnosis consistent with cholangitis was performed. Extracted data included clinical characteristics, ERCP findings, and patient outcome. The associations of ERCP overall and early ERCP with length of stay were examined. Confounding factors including severity of illness, etiology of cholangitis, and hospital type were adjusted for in a multivariate analysis. RESULTS: A total of 116 patients were studied. ERCP was performed in 71 patients with endoscopic therapy administered in 57 (80%). ERCP overall was not associated with any change in length of hospital stay. However, compared with other invasive biliary procedures, ERCP was associated with a shorter hospital stay (median 5 vs. 9.5 days, p = 0.01) and a 36% (95% CI [5%, 57%]) reduction in severity-adjusted length of stay. Patients who had early ERCP had a significantly shorter hospital stay than those who had delayed ERCP (median 4 vs. 7 days, p < 0.005) and early ERCP was associated with a 34% (95% CI [11%, 48%]) reduction in severity-adjusted length of stay. CONCLUSION: Early ERCP may be an effective strategy for shortening the length of stay in patients hospitalized with cholangitis.

 

Am J Gastroenterol 2000 Aug;95(8):1861-2

Future directions in the medical treatment of primary sclerosing cholangitis: the need for combination drug therapy.

Fong DG, Lindor KD

Publication Types:

  Comment

  Editorial

  Review

  Review, tutorial

Comments:

  Comment on: Am J Gastroenterol 2000 Aug;95(8):2015-22

 

Radiographics 2000 Jul-Aug;20(4):959-75; quiz 1108-9, 1112 [Texto completo]

Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography.

Vitellas KM, Keogan MT, Freed KS, Enns RA, Spritzer CE, Baillie JM, Nelson RC

Department of Radiology, Ohio State University Medical Center, Columbus, OH 43210, USA.

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

Publication Types:

  Review

  Review, tutorial

 

J Infect 2000 Jan;40(1):69-73

Aeromonas infection in acute suppurative cholangitis: review of 30 cases.

Chan FK, Ching JY, Ling TK, Chung SC, Sung JJ

Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese

University of Hong Kong, Shatin.

OBJECTIVES: Aeromonads, though not common pathogens in biliary sepsis, caused substantial mortality in patients with impaired hepatobiliary function. Our aim was to study the pathogenic role of Aeromonas in acute suppurative cholangitis. METHODS: Between 1996 and 1998, the medical records of patients with a diagnosis of biliary sepsis were reviewed. Those who fulfilled the diagnostic criteria for acute suppurative cholangitis and had positive bile or blood cultures for Aeromonas species were studied. RESULTS: One thousand and forty-five patients were confirmed to have acute suppurative cholangitis. Of these, 30 patients (2.9%) had Aeromonas species isolated from bile; four were complicated by aeromonas septicaemia with simultaneous recovery of the bacteria from blood. All except two isolates were A. hydrophila. Twenty-four patients (80%) had bile duct stones, four (13%) had cholangiocarcinoma and two (7%) pancreatic cancer. Twenty-five cases (83%) had previous exploration of the biliary tract. There was substantial resistance to piperacillin (58%), ceftazidime (30%) and imipenem (15%). Most patients improved after biliary decompression. Only three patients (10%) died, two had terminal malignancy and one had end-stage liver failure. No excess mortality was attributable to Aeromonas infection in biliary sepsis. CONCLUSIONS: Previous instrumentation facilitated ascending Aeromonas infection of the biliary tract from the gastrointestinal tract. Unlike early reports, our results showed that aeromonads did not adversely affect the clinical outcome of acute suppurative cholangitis with successful drainage of biliary obstruction.

 

Ann Intern Med. 1999;130:301-311. [Texto completo]

Biliary Sludge

Cynthia W. Ko, MD; John H. Sekijima, MD; and Sum P. Lee, MD, PhD

Biliary sludge was first described with the advent of ultrasonography in the 1970s. It is defined as a mixture of particulate matter and bile that occurs when solutesin bile precipitate. Its composition varies, but cholesterol monohydrate crystals, calcium bilirubinate, and other calcium salts are the most common components. The clinical course of biliary sludge varies, and complete resolution, a waxing and waning course, and progression to gallstones are all possible outcomes. Biliary sludge may cause complications, including biliary colic, acute pancreatitis, and acute cholecystitis. Clinical conditions and events associated with the formation of biliary sludge include rapid weight loss, pregnancy, ceftriaxone therapy, octreotide therapy, and bone marrow or solid organ transplantation. Sludge may be diagnosed on ultrasonography or bile microscopy, and the optimal diagnostic method depends on the clinical setting. This paper proposes a protocol for the microscopic diagnosis of sludge. There are no proven methods for the prevention of sludge formation, even in high-risk patients, and patients should not be routinely monitored for the development of sludge. Asymptomatic patients with sludge can be managed expectantly. If patients with sludge develop symptoms or complications, cholecystectomy should be considered as the definitive therapy. Further studies of the pathogenesis, natural history, and clinical associations of biliary sludge will be essential to our understanding of gallstones and other biliary tract abnormalities.

 

Gastrointest Endosc 1999 Nov;50(5):695-7

Biliary strictures and cholangitis secondary to ascariasis: endoscopic management.

al-Karawi M, Sanai FM, Yasawy MI, Mohammed AE

Department of Gastroenterology, Armed Forces Hospital, Riyadh, Saudi Arabia.

Publication Types:

  Review

  Review of reported cases

 

Hepatology 1999 Jul;30(1):325-32

Primary sclerosing cholangitis.

Angulo P, Lindor KD

Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN, USA.

Publication Types:

  Review

  Review, academic

 

Am J Gastroenterol Nov 1998;93(11):2016-2018 [Texto completo]

Role of Endoscopic Therapy in Cholangitis

John G. Lee, M.D. a

Editorial

 

World J Surg 1998 Nov;22(11):1155-61

Acute cholangitis and pancreatitis secondary to common duct stones: management update.

Raraty MG, Finch M, Neoptolemos JP

Department of Surgery, University of Liverpool, Royal Liverpool University Hospital, UK.

Gallstones are found within the main bile duct (MBD) of 7% to 20% of patients undergoing cholecystectomy. MBD stones are the commonest cause of acute cholangitis and acute pancreatitis. Acute cholangitis is the result of infection superimposed on an obstructed biliary system and carries a high mortality rate if left untreated. The mainstay of treatment is a regimen of broad-spectrum intravenous antibiotics followed by prompt decompression of the obstructed biliary tree. Decompression is best accomplished by the endoscopic route, although transhepatic approaches may also be employed. Gallstone pancreatitis may be associated with cholangitis but is also common as a separate entity. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Prophylactic cholecystectomy is recommended to prevent further episodes of gallstone pancreatitis.

Publication Types:

  Review

  Review, tutorial

 

Am J Surg 1998 Jul;176(1):34-7

Recurrent pyogenic cholangitis.

Harris HW, Kumwenda ZL, Sheen-Chen SM, Shah A, Schecter WP

Department of Surgery, San Francisco General Hospital, University of California, San Francisco, 94110-3518, USA.

BACKGROUND: Recurrent pyogenic cholangitis is a complex biliary tract disease characterized by intrahepatic pigment stones, endemic to Southeast Asia and seen with increasing frequency in the United States. The purpose of this study was to review the management of this disorder in a county hospital. METHODS: A retrospective review of 45 patients with recurrent pyogenic cholangitis evaluated between 1984 and 1995. The clinical and surgical management of patients with localized versus bilateral hepatolithiasis were compared. RESULTS: The prevalence of recurrent pyogenic cholangitis at our hospital has more than doubled since 1983. Fourteen of 45 patients (31%) had bilateral disease and required more abdominal computed tomography scans (P < 0.01), percutaneous cholangiograms (P < 0.05), endoscopies (P < 0.01), clinic visits (P < 0.05), and hospital admissions (P < 0.02) as compared with patients with localized disease. CONCLUSIONS: The effective treatment of recurrent pyogenic cholangitis requires definition of the patients' intrahepatic distribution of disease, prior to surgical intervention, and the coordinated efforts of gastroenterologists, radiologists, and surgeons.

 

Mayo Clin Proc 1998 May;73(5):479-82

Cholangitis in viral disease.

Burgart LJ

Division of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.

This review of biliary manifestations of viral diseases includes aspects of morphologic diagnosis, therapeutic implications, prognostic effect, and natural history. The viral causes of cholangitis are reviewed, with subclassification on the basis of primary hepatic versus systemic infections and immune competence of the host. Special attention is given to the histopathologic and clinical features of viruses affecting the biliary tree. Among hepatotropic viruses, hepatitis C more frequently is associated with cholangitis than is hepatitis B. In both hepatitis B and hepatitis C, the lymphocytic cholangitis duct damage is reversible and does not adversely influence the course of disease or response to therapy. Hepatitis A and hepatitis E, despite causing clinical cholestasis, do not result in severe cholangitis. The effect of systemic viruses on the biliary tree is primarily dependent on the status of the host immune system. Infants and severely immunosuppressed patients (such as those who have undergone liver transplantation) are at risk for cytomegalovirus cholangitis, whereas patients with late-stage acquired immunodeficiency syndrome (AIDS) are at risk for cholangitis due to numerous organisms. Overall, cholangitis attributable to viral disease encompasses a wide spectrum of clinicopathologic scenarios, depending on the etiologic virus and the immune competence of the host.

Publication Types:

  Review

  Review, tutorial

 

Mayo Clin Proc 1998 May;73(5):473-8

Bacterial and parasitic cholangitis.

Carpenter HA

Division of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.

Bacterial cholangitis is a clinically defined syndrome caused by the regurgitation of infected bile into the circulation. The pathogenic mechanism is unclear, and systemic sepsis may not occur. Prerequisite conditions are the presence of microorganisms in the bile and increased biliary pressure. Bacteria that commonly cause cholangitis are Escherichia coli, Klebsiella, Enterococcus, Enterobacter, Pseudomonas, and anaerobes. Although most infections are polymicrobial, this situation may not always prevail. Successful treatment depends on relieving biliary obstruction and administering antibiotics effective against bacteria in the circulation and the bile. The causes of biliary obstruction that predispose to bacterial cholangitis are myriad. Common conditions include biliary stones and benign strictures. In many parts of the world, biliary parasites are an important factor. Biliary parasites cause necrosis, inflammation, fibrosis, strictures, and cholangiectasis of the bile ducts by several mechanisms: (1) as a direct result of the irritating chemical composition of the parasite, parasitic secretions, or eggs; (2) physical obstruction of the bile ducts; (3) induction of formation of biliary stones; and (4) introduction of bacteria into the biliary system during migration from the duodenum. Therefore, bacterial cholangitis has an important and frequently dominant role in the pathogenesis and clinical course of biliary disease due to these parasitic infestations. Common biliary parasites include the nematode Ascaris lumbricoides, the trematodes Opisthorchis viverrini and felineus, Clonorchis sinensis, and Fasciola hepatica, and the cestodes Echinococcus granulosus and multilocularis. The epidemiologic, pathologic, and clinical manifestations of these parasitic infestations are reviewed.

Publication Types:

  Review

  Review, tutorial

 

Am J Gastroenterol 1998 Apr;93(4):515-23

Primary sclerosing cholangitis: a clinical review.

Ponsioen CI, Tytgat GN

Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.

Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterized by fibro-obliterative inflammation of the entire biliary tree. It is a slowly progressive disease with an undulating course, resulting in terminal biliary cirrhosis after a median period of about 12 years after diagnosis. The etiology of the disease is unknown and there is no effective therapy that can halt disease progression. Around 8% of PSC patients develop cholangiocarcinoma, which, by the time it is diagnosed, cannot be treated curatively. The purpose of this article is to review the current knowledge about primary sclerosing cholangitis and to speculate on future strategies to address the issues of etiology and therapy.

Publication Types:

  Review

  Review literature

 

Mayo Clin Proc 1998 Apr;73(4):380-5

Ischemic cholangitis.

Batts KP

Division of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.

Ischemia-induced bile duct lesions have been collectively labeled as ischemic cholangitis. The biliary epithelium is dependent on arterial blood flow, unlike the hepatic parenchyma with its dual arterial and portal venous blood supply. As such, the biliary epithelium is susceptible to injury when arterial blood flow is compromised. This compromise can occur at the level of the major, named hepatic artery branches or at the microscopic, peribiliary capillary plexus level. Typically, ischemic cholangitis manifests as segmental strictures and cholangiectases with resultant mechanical impairment of bile flow and, occasionally, secondary infection of the biliary system. Ischemic cholangitis after liver transplantation is becoming an important problem and likely is attributable to numerous factors. Hepatic arterial infusion of chemotherapy and systemic vasculitis are other causes of ischemic cholangitis. The role of ischemia in other chronic biliary and ductopenic diseases remains speculative.

Publication Types:

  Review

  Review, tutorial

 

Gastrointest Endosc 1997 May;45(5):435-6

An impacted metallic clip at the ampulla causing ascending cholangitis.

Venu RP, Brown RD, Rosenthal G, Deutch SF, LoGuidice JA, Pastika B, Caniglio B

Department of Medicine, University of Illinois, Chicago, USA.

Publication Types:

  Review

  Review of reported cases

 

Med Clin (Barc) 1996 Sep 21;107(9):338-41

[Distal intrahepatic biliary tract diseases in adults: cholangitis and loss of ducts].

[Article in Spanish]

Bruguera M

Servicio de Hepatologia, Hospital Clinic i Provincial, Barcelona.

Publication Types:

  Review

  Review, tutorial

 

Annals of Internal Medicine, 15 September 1996. 125:442-447. [Texto completo]

Piperacillin To Prevent Cholangitis after Endoscopic Retrograde Cholangiopancreatography A Randomized, Controlled Trial

Sven J. van den Hazel, MD, PhD; Peter Speelman, MD, PhD; Jacob Dankert, MD, PhD; Kees Huibregtse, MD, PhD; Guido N.J. Tytgat, MD, PhD; and Dirk J. van Leeuwen, MD, PhD

Background: Cholangitis does not often occur after endoscopic retrograde cholangiopancreatography (ERCP), but it can be a serious complication of this procedure. Antibiotic prophylaxis is therefore frequently used in patients having ERCP, but existing data are insufficient to allow evaluation of the effectiveness of this practice. Objective: To determine the efficacy of single-dose antibiotic prophylaxis with piperacillin for ERCP-induced cholangitis. Design: Randomized, double-blind, placebo-controlled clinical trial. Setting: Tertiary referral center for ERCP. Patients: Patients who had ERCP for suspected biliary tract stones or distal common bile duct stricture were eligible. Major exclusion criteria were previous ERCP within 7 days, biliary endoprosthesis in situ, and use of antimicrobial agents or presence of fever within 7 days before the procedure. Intervention: Piperacillin, 4 g, or placebo was given intravenously approximately 30 minutes before ERCP. Measurements: Duration of follow-up was 1 week. Acute cholangitis was diagnosed if a patient had a body temperature greater than 38 C, a clinically apparent need for antibiotic treatment, and no symptoms indicating infection outside of the biliary tree. Results: 551 consecutive patients were enrolled. During ERCP, stones were found in 147 patients, malignant distal strictures were found in 203 patients, other pathologic findings were seen in 88 patients, and normal biliary tracts were seen in 113 patients. Seventeen of the 281 patients who received placebo (6.0%) and 12 of the 270 patients who received piperacillin (4.4%) developed acute cholangitis (relative risk, 0.73 [95% CI, 0.36 to 1.51]). The absolute risk reduction was 1.6% (CI, -5.3% to 2.1%). All cases of cholangitis (with the exception of one case seen in a patient in the piperacillin group) were mild or moderate in severity.

Conclusion: Single-dose prophylaxis with piperacillin is not associated with a clinically significant reduction in the incidence of acute cholangitis after ERCP in patients suspected of having biliary tract stones or distal common bile duct stricture.

 

Am J Gastroenterol 1996 Jul;91(7):1477-8

Bacillus subtilis as a cause of cholangitis in polycystic kidney and liver disease.

Wallet F, Crunelle V, Roussel-Delvallez M, Fruchart A, Saunier P, Courcol RJ

Publication Types:

  Letter

  Review

  Review of reported cases

 

Clin Infect Dis 1994 Aug;19(2):279-86

Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis.

van den Hazel SJ, Speelman P, Tytgat GN, Dankert J, van Leeuwen DJ

Department of Gastroenterology, University of Amsterdam, The Netherlands.

Cholangitis is usually the consequence of a combination of factors: impairment of the flow of bile and bacterial colonization of the biliary tract. Although reestablishing biliary drainage is the mainstay of treatment, antibiotics play an important role in the management of cholangitis. In this review, the use of antibiotics for treatment, prophylaxis, and maintenance therapy is discussed. Antibiotics for the treatment of acute cholangitis should be given for 7-10 days in therapeutic dosages and may allow a more selective timing of further interventions. Antibiotic prophylaxis for cholangitis ought to be given as a single (high) dose shortly before surgical or nonsurgical manipulations of the biliary system. Patients with a compromised biliary system (e.g., on account of an endoprosthesis in situ or hepaticojejunostomy) who are prone to develop recurrent bouts of cholangitis may benefit from antibiotic maintenance therapy, given daily in lower-than-therapeutic dosages.

Publication Types:

  Review

  Review, tutorial

 

Med Clin North Am 1993 Sep;77(5):1015-36

Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis.

Kadakia SC

Gastroenterology Service, Brooke Army Medical Center, San Antonio, Texas.

Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations
either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

Publication Types:

  Review

  Review, academic

 

 

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