Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

BACKGROUND Whether clinical outcomes of acute cholangitis(AC)vary by etiology is unclear.AIM To compare outcomes in AC caused by malignant biliary obstruction(MBO)and common bile duct stones(CBDS).METHODS This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography(ERCP)due to AC caused by MBO(MBO group,n=56)and CBDS(CBDS group,n=460).Clinical and laboratory parameters were compared between the groups.Propensity score matching(PSM)created 55 matched pairs.Confounders used in the PSM analysis were age,sex,time to ERCP,and technical success of ERCP.The primary outcome comparison was 30-d mortality.The secondary outcome comparisons were intensive care unit(ICU)admission rate,length of hospital stay(LOHS),and 30-d readmission rate.RESULTS Compared with the CBDS group,the MBO group had significantly lower body temperature,percentage of abnormal white blood cell counts,and serum levels of aspartate aminotransferase,alanine aminotransferase,and creatinine.Body temperature,percent abnormal white blood cell count,and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis.Platelet count,prothrombin time/international normalized ratio,and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group.The MBO group had a significantly higher percentage of severe AC(33.9%vs 22.0%,P=0.045)and received ERCP later(median,92.5 h vs 47.4 h,P<0.001).However,the two differences were not found in the PSM analysis.The 30-d mortality(5.4%vs 0.7%,P=0.019),ICU admission rates(12.5%vs 4.8%,P=0.028),30-d readmission rates(23.2%vs 8.0%,P<0.001),and LOHS(median,16.5 d vs 7.0 d,P<0.001)were significantly higher or longer in the MBO group.However,only LOHS remained significant in the PSM analysis.Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality.CONCLUSION MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients.Therefore,clinicians should remain vigilant in MBO patients with clinically suspected AC,and perform ERCP for biliary drainage as soon as possible.

Endoscopic diagnosis of cervical esophageal heterotopic gastric mucosa with conventional and narrow-band images

AIM:To compare the diagnostic yield of heterotopic gastric mucosa(HGM)in the cervical esophagus with conventional imaging(CI)and narrow-band imaging(NBI).METHODS:A prospective study with a total of 760patients receiving a CI examination(mean age 51.6years;47.8%male)and 760 patients undergoing NBI examination(mean age 51.2 years;45.9%male).The size of HGM was classified as small(1-5 mm),medium(6-10 mm),or large(>1 cm).A standardized questionnaire was used to obtain demographic characteristics,social habits,and symptoms likely to be related to cervical esophageal HGM,including throat symptoms(globus sensation,hoarseness,sore throat,and cough)and upper esophageal symptoms(dysphagia and odynophagia)at least 3 mo in duration.The clinicopathological classification of cervical esophageal HGM was performed using the proposal by von Rahden et al.RESULTS:Cervical esophageal HGM was found in 36of 760(4.7%)and 63 of 760(8.3%)patients in the CI and NBI groups,respectively(P=0.007).The NBI mode discovered significantly more small-sized HGM than CI(55%vs 17%;P<0.0001).For the 99 patients with cervical esophageal HGM,biopsies were performed in 56 patients;37(66%)had fundic-type gastric mucosa,and 19 had antral-type mucosa.For the clinicopathological classification,77 patients(78%)were classified as HGMⅠ(asymptomatic carriers);21 as HGMⅡ(symptomatic without morphologic changes);and one as HGMⅢ(symptomatic with morphologic change).No intraepithelial neoplasia or adenocarcinoma was found.CONCLUSION:NBI endoscopy detects more cervical esophageal HGM than CI does.Fundic-type gastric mucosa constitutes the most common histology.One-fifth of patients have throat or dysphagic symptoms.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

AIM:To describe characteristics of a poorly expandable(PE) common bile duct(CBD) with stones on endoscopic retrograde cholangiography.METHODS:A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment.Between 2003 and 2006,endoscopic retrograde cholangiography(ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital.Patients with characteristic PE bile duct on ERC were identified from the database.Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS:A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study.The median patient age was 45 years(range,20 to 92 years);66.7% of the patients were men.The diameters of the widest non-PE CBD segment,the PE segment,and the largest stone were 14.3 ± 4.9 mm,5.8 ± 1.6 mm,and 11.2 ± 4.7 mm,respectively.The length of the PE segment was 39.7 ± 15.4 mm(range,12.3 mm to 70.9 mm).To remove the CBD stone(s) completely,mechanical lithotripsy was required in 25(83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature.The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy.Post-ERC complications occurred in 4 cases:pancreatitis in 1,cholangitis in 2,and an impacted Dormia basket with cholangitis in 1.Two(6.7%) of the 28 patients developed recurrent CBD stones at follow-up(50 ± 14 mo) and were successfully managed with therapeutic ERC.CONCLUSION:Patients with a PE duct frequently require mechanical lithotripsy for stones extraction.To retrieve stones successfully and avoid complications,these patients should be identified during ERC.

Treating delayed endoscopic sphincterotomy-induced bleeding:Epinephrine injection with or without thermotherapy

AIM:To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed post-endoscopic sphincterotomy (ES) bleeding.METHODS: Cases with delayed post-ES bleeding undergoing epinephrine injection alone (epinephrine injection group, n=26) or epinephrine combined with thermotherapy (combination therapy group, n=33) in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements wereRESULTS: The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy (P=0.44). There were four patients with re-bleeding in each group (16.0% vs 12.1%, P=0.72). There was only one complication of pancreatitis from the combination therapy group. Three patients (11.5%) in the epinephrine injection group and one patient (3%) in the combination therapy group required angiographic embolization or surgery (P=0.31). The total number of blood transfusions was not significantly different between the two groups (3.5±4.6 U vs 3.5±4.5 U, P=0.94). There was no bleeding-related death in either group.CONCLUSION: Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post-ES bleeding.

Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth Ⅱ gastrectomy

AIM:To evaluate the effect of double balloon endoscope(DBE)on the endoscopic retrograde cholangio-pancreatography(ERCP)success rate in patients with a history of BillrothⅡ(BⅡ)gastrectomy.METHODS:From April 2006 to March 2007,32 patients with a BⅡgastrectomy underwent 34 ERCP attempts.In all cases,the ERCP procedures were started using a duodenoscope.If intubation of the afferent loop or reaching the papilla failed,we changed to DBE for the ERCP procedure(DBE-ERCP).We assessed the success rate of afferent loop intubation,reaching the major papilla,selective cannulation,possibility of therapeutic approaches,procedure-related complications,and the overall success rate.RESULTS:Among the 32 patients with a history of BⅡgastrectomy,the duodenoscope was successfully passed up to the papilla in 22 patients(69%),and cannulation was successfully performed in 20 patients(63%).Six patients(2 with failure in afferent loop intubation and 4 with failure in reaching the papilla)underwent DBE-ERCP.The DBE reached the papilla in all the 6 patients(100%)and selective cannulation was successful in 5 patients(83%).Four patients(67%)who had common bile duct stones were successfully treated.One patient underwent diagnostic ERCP only and the other one,in whom selective cannulation failed,was diagnosed with papilla cancer proven by biopsy.There were no complications related to the DBE.The overall ERCP success rate increased to 88%(28/32).CONCLUSION:The overall ERCP success rate increases with DBE in patients with a previous BⅡgastrectomy.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography(ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct(CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIM To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODS From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.RESULTS Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas(P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis(odds ratio 5.82, P = 0.002;0.12, P = 0.008, respectively).CONCLUSION Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography(ERCP)in acute cholangitis(AC) is uncertain,especially in patients with AC of varying severity.AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.METHODS According to the 2018 Tokyo guidelines,683 patients who met the definite diagnostic criteria for AC were retrospectively identified.The results were first compared between patients receiving ERCP ≤ 24 h and>24 h and then between patients receiving ERCP ≤ 48 h and>48 h.Subgroup analyses were performed in patients with grade Ⅰ,Ⅱ or Ⅲ AC.The primary outcome was 30-d mortality.Secondary outcomes were intensive care unit(ICU) admission rate,length of hospital stay(LOHS) and 30-d readmission rate.RESULTS Taking 24 h as the critical value,compared with ERCP>24 h,malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group(5.2% vs 11.5%).The proportion of cardiovascular dysfunction(11.2% vs 2.6%),respiratory dysfunction(14.2% vs 5.3%),and ICU admission(11.2% vs 4%)in the ERCP ≤ 24 h group was significantly higher,while the LOHS was significantly shorter(median,6 d vs 7 d).Stratified by the severity of AC,higher ICU admission was only observed in grade Ⅲ AC and shorter LOHS was only observed in grade Ⅰ and Ⅱ AC.There were no significant differences in 30-d mortality between groups,either in the overall population or in patients with grade Ⅰ,Ⅱ or Ⅲ AC.With 48 h as the critical value,compared with ERCP>48 h,the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group(81.5% vs 68.3%).The ERCP ≤ 48 h group had significantly lower 30-d mortality(0 vs 1.9%) and shorter LOHS(6 d vs 8 d).Stratified by AC severity,lower 30-d mortality(0 vs 6.1%) and higher ICU admission rates(22.2% vs 10.2%) were only observed in grade Ⅲ AC,and shorter LOHS was only observed in grade I and Ⅱ AC.In the multivariate analysis,cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.CONCLUSION ERCP ≤ 48 h conferred a survival benefit in patients with grade Ⅲ AC.Early ERCP shortened the LOHS in patients with grade Ⅰ and Ⅱ AC.