Endosc 2000 Oct;52(4):484-9
of ERCP in cholangitis: A community-based study.
A, Cooper GS, Lloyd LE, Hammar PJ, Issa K, Rosenthal GE
of Gastroenterology, University Hospitals of Cleveland and MetroHealth
Medical Center, Case Western Reserve University; and Quality Information
Management Corporation, Cleveland, Ohio.
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.
J Gastroenterol 2000 Aug;95(8):1861-2
directions in the medical treatment of primary sclerosing cholangitis: the
need for combination drug therapy.
DG, Lindor KD
Comment on: Am J Gastroenterol 2000 Aug;95(8):2015-22
2000 Jul-Aug;20(4):959-75; quiz 1108-9, 1112 [Texto
manifestations of sclerosing cholangitis with emphasis on MR
KM, Keogan MT, Freed KS, Enns RA, Spritzer CE, Baillie JM, Nelson RC
of Radiology, Ohio State University Medical Center, Columbus, OH 43210,
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
Infect 2000 Jan;40(1):69-73
infection in acute suppurative cholangitis: review of 30 cases.
FK, Ching JY, Ling TK, Chung SC, Sung JJ
of Medicine & Therapeutics, Prince of Wales Hospital, Chinese
of Hong Kong, Shatin.
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.
Intern Med. 1999;130:301-311. [Texto
W. Ko, MD; John H. Sekijima, MD; and Sum P. Lee, MD, PhD
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.
Endosc 1999 Nov;50(5):695-7
strictures and cholangitis secondary to ascariasis: endoscopic management.
M, Sanai FM, Yasawy MI, Mohammed AE
of Gastroenterology, Armed Forces Hospital, Riyadh, Saudi Arabia.
Review of reported cases
P, Lindor KD
of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester,
J Gastroenterol Nov 1998;93(11):2016-2018 [Texto
of Endoscopic Therapy in Cholangitis
G. Lee, M.D. a
J Surg 1998 Nov;22(11):1155-61
cholangitis and pancreatitis secondary to common duct stones: management
MG, Finch M, Neoptolemos JP
of Surgery, University of Liverpool, Royal Liverpool University Hospital,
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.
J Surg 1998 Jul;176(1):34-7
HW, Kumwenda ZL, Sheen-Chen SM, Shah A, Schecter WP
of Surgery, San Francisco General Hospital, University of California, San
Francisco, 94110-3518, USA.
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
Clin Proc 1998 May;73(5):479-82
in viral disease.
of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.
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.
Clin Proc 1998 May;73(5):473-8
and parasitic cholangitis.
of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.
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.
J Gastroenterol 1998 Apr;93(4):515-23
sclerosing cholangitis: a clinical review.
CI, Tytgat GN
of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam,
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.
Clin Proc 1998 Apr;73(4):380-5
of Anatomic Pathology, Mayo Clinic Rochester, Minnesota 55905, USA.
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.
Endosc 1997 May;45(5):435-6
impacted metallic clip at the ampulla causing ascending cholangitis.
RP, Brown RD, Rosenthal G, Deutch SF, LoGuidice JA, Pastika B, Caniglio B
of Medicine, University of Illinois, Chicago, USA.
Review of reported cases
Clin (Barc) 1996 Sep 21;107(9):338-41
intrahepatic biliary tract diseases in adults: cholangitis and loss of
de Hepatologia, Hospital Clinic i Provincial, Barcelona.
of Internal Medicine, 15 September 1996. 125:442-447. [Texto
To Prevent Cholangitis after Endoscopic Retrograde
Cholangiopancreatography A Randomized, Controlled Trial
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
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
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.
J Gastroenterol 1996 Jul;91(7):1477-8
subtilis as a cause of cholangitis in polycystic kidney and liver disease.
F, Crunelle V, Roussel-Delvallez M, Fruchart A, Saunier P, Courcol RJ
Review of reported cases
Infect Dis 1994 Aug;19(2):279-86
of antibiotics in the treatment and prevention of acute and recurrent
den Hazel SJ, Speelman P, Tytgat GN, Dankert J, van Leeuwen DJ
of Gastroenterology, University of Amsterdam, The Netherlands.
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.
Clin North Am 1993 Sep;77(5):1015-36
tract emergencies. Acute cholecystitis, acute cholangitis, and acute
Service, Brooke Army Medical Center, San Antonio, Texas.
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.