Acute suppurative terminal cholangitis:Clinical characteristics of a new subtype of acute cholangitis

Background:Acute suppurative terminal cholangitis(ASTC)is rarer than acute obstructive cholangitis and is not well studied.To explore this subtype of acute cholangitis,we described our clinical experience with ASTC.Methods:We performed a retrospective review of patients with ASTC admitted to our center from September 2014 to August 2020.We analyzed their clinical characteristics,including etiology,clinical manifestations,imaging features,treatment and prognosis.Results:A total of 32 ASTC patients were included in the analysis.The majority of the patients had a history of biliary operations,and clinical manifestations were occult and atypical.The positive rate of bacterial culture was 46.9%.All the patients had typical imaging features on computed tomography and magnetic resonance imaging.Treatment with effective antibiotics was provided as soon as diagnosis was established.After treatment,most patients had a good outcome.Elevated levels of total bilirubin,aspartate aminotransferase,procalcitonin and gamma-glutamyltransferase were the characteristics of critically ill patients and were associated with relatively poor prognosis.Conclusions:Our results demonstrated that ASTC should be recognized as a new subtype of acute cholangitis,and that earlier diagnosis and more personalized treatments are needed.

Response letter to “Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the outcomes?” with imaging aspects

Radiological imaging findings may contribute to the differentiation of malignant biliary obstruction from choledocholithiasis in the etiology of acute cholangitis.

Red cell distribution width-to-albumin ratio is a simple promising prognostic marker in acute cholangitis requiring biliary drainage

Background: It is crucial to assess the severity of acute cholangitis(AC). There are currently several prognostic markers. However, the accuracies of these markers are not satisfied. The present study aimed to investigate the predictive value of the red cell distribution width(RDW)-to-albumin ratio(RAR) for the prognosis of AC. Methods: We retrospectively evaluated consecutive patients diagnosed with AC between May 2019 and March 2022. RAR was calculated, and its predictive ability for in-hospital mortality, intensive care unit(ICU) admission, bacteremia, and the length of hospitalization were analyzed. Results: Out of 438 patients, 34(7.8%) died. Multivariate analysis showed that malignant etiology [odds ratio(OR) = 4.816, 95% confidence interval(CI): 1.936-11.980], creatinine(OR = 1.649, 95% CI: 1.095-2.484), and RAR(OR = 2.064, 95% CI: 1.494-2.851) were independent risk factors for mortality. When adjusted for relevant covariates, including age, sex, malignant etiology, Tokyo severity grading(TSG), Charlson comorbidity index, and creatinine, RAR significantly predicted mortality(adjusted OR = 1.833, 95% CI: 1.280-2.624). When the cut-off of RAR was set to 3.8, its sensitivity and specificity for mortality were 94.1% and 56.7%, respectively. Patients with an RAR of > 3.8 had a 20.9-fold(OR = 20.9, 95% CI: 4.9-88.6) greater risk of mortality than the remaining patients. The area under the curve value of RAR for mortality was 0.835(95% CI: 0.770-0.901), which was significantly higher than that of TSG and the other prognostic markers, such as C-reactive protein-to-albumin ratio, and procalcitonin-to-albumin ratio. Lastly, RAR was not inferior to TSG in predicting ICU admission, bacteremia, and the length of hospitalization. Conclusions: RAR successfully predicted the in-hospital mortality, ICU admission, bacteremia, and the length of hospitalization of patients with AC, especially in-hospital mortality. RAR is a promising marker that is more convenient than TSG and other prognostic markers for predicting the prognosis of patients with AC.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity scorematched analysis

BACKGROUND During emergency endoscopic retrograde cholangiopancreatography(ERCP),the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis(AC)due to choledocholithiasis are unclear.AIM To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC.METHODS We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023.The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later,employing a propensity score(PS)frame-work.Our primary outcomes were intensive care unit(ICU)admission rates,ICU length of stay,and duration of antibiotic use.RESULTS In total,we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention:The urgent group(≤24 h,n=102)and the elective group(>24 h,n=152).Ninety-three pairs of patients with similar characteristics were selected by PS matching.The urgent ERCP group had more ICU admissions(34.4%vs 21.5%,P=0.05),shorter ICU stays(3 d vs 9 d,P<0.001),fewer antibiotic use(6 d vs 9 d,P<0.001),and shorter hospital stays(9 d vs 18.5 d,P<0.001).There were no significant differences observed in adverse events,in-hospital mortality,recurrent cholangitis occurrence,30-d readmission rate or 30-d mortality.CONCLUSION Urgent one-stage ERCP provides the advantages of a shorter ICU stay,a shorter duration of antibiotic use,and a shorter hospital stay.

Impact of index admission cholecystectomy vs interval cholecystectomy on readmission rate in acute cholangitis: National Readmission Database survey

BACKGROUND Elective cholecystectomy(CCY)is recommended for patients with gallstone-related acute cholangitis(AC)following endoscopic decompression to prevent recurrent biliary events.However,the optimal timing and implications of CCY remain unclear.AIM To examine the impact of same-admission CCY compared to interval CCY on patients with gallstone-related AC using the National Readmission Database(NRD).METHODS We queried the NRD to identify all gallstone-related AC hospitalizations in adult patients with and without the same admission CCY between 2016 and 2020.Our primary outcome was all-cause 30-d readmission rates,and secondary outcomes included in-hospital mortality,length of stay(LOS),and hospitalization cost.RESULTS Among the 124964 gallstone-related AC hospitalizations,only 14.67%underwent the same admission CCY.The all-cause 30-d readmissions in the same admission CCY group were almost half that of the non-CCY group(5.56%vs 11.50%).Patients in the same admission CCY group had a longer mean LOS and higher hospitalization costs attrib-utable to surgery.Although the most common reason for readmission was sepsis in both groups,the second most common reason was AC in the interval CCY group.CONCLUSION Our study suggests that patients with gallstone-related AC who do not undergo the same admission CCY have twice the risk of readmission compared to those who undergo CCY during the same admission.These readmis-sions can potentially be prevented by performing same-admission CCY in appropriate patients,which may reduce subsequent hospitalization costs secondary to readmissions.

Short vs long-course antibiotic therapy in adults with acute cholangitis:A systematic review,meta-analysis,and evidence quality assessment

BACKGROUND Acute cholangitis(AC)constitutes an infection with increased mortality rates in the past.Due to new diagnostic tools and therapeutic methods,the mortality of AC has been significantly reduced nowadays.The initial antibiotic treatment of AC has been oriented to the most common pathogens connected to this infection.However,the optimal duration of the antibiotic treatment of AC is still debatable.AIM To investigate if shorter-course antibiotic treatments could be similarly effective to long-course treatments in adults with AC.METHODS This study constitutes a systematic review and meta-analysis of the existing literature concerning the duration of antibiotic therapy of AC and an assessment of the quality of the evidence.The study was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses.Fifteen studies were included in the systematic review,and eight were eligible for meta-analysis.Due to heterogeneous duration cutoffs,three study-analysis groups were formed,with a cutoff of 2-3,6-7,and 14 d.RESULTS A total of 2763 patients were included in the systematic review,and 1313 were accounted for the meta-analysis.The mean age was 73.66±14.67 years,and the male and female ratio was 1:08.No significant differences were observed in the mortality rates of antibiotic treatment of 2-3 d,compared to longer treatments(odds ratio=0.78,95% confidence interval:0.23-2.67,I2=9%)and the recurrence rates and hospitalization length were also not different in all study groups.CONCLUSION Short-and long-course antibiotic treatments may be similarly effective concerning the mortality and recurrence rates of AC.Safe conclusions cannot be extracted concerning the hospitalization duration.

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.

Predictive value of presepsin and acylcarnitines for severity and biliary drainage in acute cholangitis

BACKGROUND Bacteremia,which is a major cause of mortality in patients with acute cholangitis,induces hyperactive immune response and mitochondrial dysfunction.Presepsin is responsible for pathogen recognition by innate immunity.Acylcarnitines are established mitochondrial biomarkers.AIM To clarify the early predictive value of presepsin and acylcarnitines as biomarkers of severity of acute cholangitis and the need for biliary drainage.METHODS Of 280 patients with acute cholangitis were included and the severity was stratified according to the Tokyo Guidelines 2018.Blood presepsin and plasma acylcarnitines were tested at enrollment by chemiluminescent enzyme immunoassay and ultra-high-performance liquid chromatography-mass spectrometry,respectively.RESULTS The concentrations of presepsin,procalcitonin,short-and medium-chain acylcarnitines increased,while long-chain acylcarnitines decreased with the severity of acute cholangitis.The areas under the receiver operating characteristic curves(AUC)of presepsin for diagnosing moderate/severe and severe cholangitis(0.823 and 0.801,respectively)were greater than those of conventional markers.The combination of presepsin,direct bilirubin,alanine aminotransferase,temperature,and butyryl-L-carnitine showed good predictive ability for biliary drainage(AUC:0.723).Presepsin,procalcitonin,acetyl-L-carnitine,hydroxydodecenoyl-Lcarnitine,and temperature were independent predictors of bloodstream infection.After adjusting for severity classification,acetyl-L-carnitine was the only acylcarnitine independently associated with 28-d mortality(hazard ratio 14.396;P<0.001)(AUC:0.880).Presepsin concentration showed positive correlation with direct bilirubin or acetyl-L-carnitine.CONCLUSION Presepsin could serve as a specific biomarker to predict the severity of acute cholangitis and need for biliary drainage.Acetyl-L-carnitine is a potential prognostic factor for patients with acute cholangitis.Innate immune response was associated with mitochondrial metabolic dysfunction in acute cholangitis.

Timing of biliary decompression for acute cholangitis

Severe acute cholangitis(AC)exacerbates the risk of death because of the rapid progression of the disease.The optimal timing of biliary decompression(BD)as a necessary intervention in patients with severe AC is controversial.A recently report titled“Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity”in the World Journal of Gastroenterology that the optimal time of endoscopic retrograde cholangiopancreatography for treating patients with severe AC is≤48 but not≤24 h,providing clinical evidence for selecting the optimal time for implementation of BD.Here,we discuss the controversy over the optimal timing of BD for AC based on guidelines and clinical evidence,and consider that more high-level clinical researches are urgent needed to benefit the management of patients with different severity of AC.

In vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens of acute cholangitis

AIM：To analyze the in vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens isolated from patients with acute cholangitis. METHODS： In this prospective study a total of 65 patients with acute cholangitis due to biliary stone obstruction （n = 7）, benign biliary stricture （n = 16）, and malignant biliary stricture （n = 42） were investigated with regard to spectrum of bacterial infection and antibiotic resistance. Pathogens were isolated from bile cultures in all study patients. In 22 febrile patients, blood cultures were also obtained. In vitro activity of moxifloxacin and piperacillin/ sulbactam was determined by agar diffusion. RESULTS： Thirty-one out of 65 patients had positive bile and/or blood cultures. In 31 patients, 63 isolates with 17 different species were identified. The predominant strains were Enterococcus species （26/63）, Ecoli （13/63） and Klebsiella species （8/63）. A comparable in vitro activity of moxifloxacin and piperacillin/sulbactam was observed for E.coli and Klebsiella species. In contrast, Enterococcus species had higher resistances towards moxifloxacin. Overall bacteria showed antibiotic resistances in vitro of 34.9% for piperacillin/sulbactam and 36.5% for moxifioxacin.CONCLUSION： Enterococcus species, E.co/i and Klebsiella species were the most common bacteria isolated from bile and/or blood from patients with acute cholangitis. Overall, a mixed infection with several species was observed, and bacteria showed a comparable in vitro activity for piperacillin/sulbactam and moxifloxacin.

Endoscopic management of acute cholangitis in elderly patients

AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupⅠ, age < 60 years; group Ⅱ, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group Ⅱ compared to 120 of 123 in groupⅠ. High fever (fever ≥ 38.0℃) was more common in groupⅠ(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group Ⅱ. Biliopancreatic malignancy was a common cause of biliary obstruction in group Ⅱ (n = 34) and benign diseases in groupⅠ(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0℃ (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupⅠand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group Ⅱ. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupⅠ, 24 group Ⅱ, stent: 64 groupⅠ, 28 group Ⅱ) without any significant age related difference in the success rate. Abdominalpain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupⅠ(2-15 d) compared to 10 d in 47 patients of group Ⅱ (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupⅠcompared to 15 d (5-26 d) in 47 patients in group Ⅱ. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group Ⅱ and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group Ⅱ despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group Ⅱ patients (16.4 ± 5.6, 7-30 d) than in groupⅠpatients (8.2 ± 2.4, 7-20 d).CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.

Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients

BACKGROUND： Acute cholangitis in old people is a cause of mortality and prolonged hospital stay. We evaluated the effects of methods and timing of biliary drainage on the outcomes of acute cholangitis in elderly and very elderly patients. METHODS： We analyzed 331 patients who were older than 75 years and were diagnosed with acute calculous cholangitis. They were admitted to our hospital from 2009 to 2014. Patients＇ demographics, severity grading, methods and timing of biliary drainage, mortality, and hospital stay were retrospectively obtained from medical records. Clinical parameters and outcomes were compared between elderly （75-80 years, n= 156） and very elderly （≥81 years, n=175） patients. We analyzed the effects of methods [none, endoscopic retrograde cholangio- pancreatography （ERCP）, percutaneous transhepatic biliary drainage, or failure] and timing （urgent or early） of biliary drainage on mortality and hospital stay in these patients. RESULTS： Acute cholangitis in older patients manifested as atypical symptoms characterized as infrequent Charcot＇s triad （4.2%） and comorbidity in one-third of the patients. Patients were graded as mild, moderate, and severe cholangitis in 104 （31.4%）, 175 （52.9%）, and 52 （15.7%）, respectively. Urgent bili-ary drainage （≤24 hours） was performed for 80.5% （247/307） of patients. Very elderly patients tended to have more severe grades and were treated with sequential procedures of transient hiliary drainage and stone removal at different sessions. Hospital stay was related to methods and timing of biliary drainage. Mortality was very low （1.5%） and not related to patient age but rather to the success or failure of biliary drainage and severity grading of the acute cholangitis. CONCLUSIONS： The methods and timing used for biliary drainage and severity of cholangitis are the major determinants of mortality and hospital stay in elderly and very elderly patients with acute cholangitis. Urgent successful ERCP is mandatory for favorable prognosis in these patients.

Activation of TLR-4 and liver injury via NF-kappa B in rat with acute cholangitis

BACKGROUND: Toll-like receptors (TLRs) are a family of type 1 transmembrane receptors, which can recognize different pathogen-associated molecular patterns. Among them, TLR-4 is specific to lipopolysaccharide. It transfers the infection signal into the cell and promotes the translocation of nuclear factor kappa B (NF-kappa B) to the nucleus and the subsequent transcriptional activation of genes encoding pro- and anti-inflammatory cytokines and chemokines. Acute cholangitis (AC) is a common biliary tract infection in oriental countries, and often leads to liver injury. The activation of TLR-4 and its significance in liver injury in rats with AC remain unclear. METHODS: Rat models of AC (biliary tract obstruction+E. coli injection, n=36) and control models (biliary tract obstruction+saline, n=18) were made. Liver tissue injury was investigated by pathological examination. The levels of serum TNF-alpha and IL-10 were measured by enzyme-linked immunosorbent assay, and the expressions of TLR-4, NF-kappa B mRNAs and proteins in the liver were detected by RT-PCR, immunohistochemical staining and Western blotting, respectively. RESULTS: Severe liver tissue injury in rats with AC was evident as shown by pathological examination. TLR-4 and NF-kappa B were strongly expressed in the cytoplasm of hepatocytes in the AC group. They were negative or slightly positive in the control group. TLR-4 mRNA and protein in the liver of rats with AC increased 1 hour after biliary tract ligation and E. coli injection, and peaked at 6 hours after surgery. Twenty-four hours later, they began to decrease. The expression of TLR-4 was paralleled by that of NF-kappa B in the liver and TNF-alpha in serum. CONCLUSION: The higher expression of TLR-4 in the liver of rats with AC may be involved in liver injury through the activation of NF-kappa B and release of cytokines such as TNF-alpha.

Catheterization of the gallbladder: A novel mouse model of severe acute cholangitis

AIM To establish a severe acute cholangitis(SAC) model in mice.METHODS Cholecystic catheterization was performed under the condition of bile duct ligation(BDL). Trans-cholecystic injection of lipopolysaccharide(LPS) was defined as the SAC animal model. Sham operation group, intraperitoneal injection of LPS without BDL group, intraperitoneal injection of LPS with BDL group and trans-cholecystic injection of normal saline with BDL group were defined as control groups. The survival rates and tissue injuries in liver, lungs and kidney were evaluated.RESULTS Mice in the SAC group showed a time-dependent mortality and much more severe tissue injuries in liver, lungs and kidney, compared with other groups. However, relieving biliary obstruction could effectively reduce mortality and attenuate liver injury in the SAC mouse model.CONCLUSION Trans-cholecystic injection of LPS under the condition of biliary obstruction could establish a repeatable and reversible mouse model of SAC.

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.

Optimal timing of biliary drainage based on the severity of acute cholangitis:A single-center retrospective cohort study

BACKGROUND Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis(AC).Although early biliary drainage is recommended by the treatment guidelines for AC,the best time for performing this procedure is yet to be established.Furthermore,since the clinical outcomes of patients with severe AC vary dramatically,screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIM To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODS In this retrospective monocenter cohort analysis,we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020.Demographic characteristics including age and sex,clinical and laboratory characteristics,and imaging findings of each patient were obtained from electronic medical records.We investigated the all-cause in-hospital mortality(IHM),hospital length of stay(LOS),and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors[age,white blood cell(WBC)count,total bilirubin,albumin,lactate,malignant obstruction,and Charlton comorbidity index(CCI)].RESULTS Biliary drainage within 24 or 48 h in Grade Ⅲ AC patients could dramatically decrease IHM(3.9%vs 9.0%,P=0.041;4%vs 9.9%,P=0.018,respectively),while increasing LOS and hospitalization costs.Multivariate logistic analysis revealed that neurological,respiratory,renal,and cardiovascular dysfunctions,hypoalbuminemia,and malignant obstruction were significantly associated with IHM(odds ratio=5.32,2.541,6.356,4.021,5.655,and 7.522;P<0.001,P=0.016,P<0.001,P=0.012,P<0.001,and P<0.001;respectively).Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction(0%vs 17.3%,P=0.041)or with serum lactate>2 mmol/L(0%vs 5.4%,P=0.016).In the subgroup of AC patients with renal dysfunction,abnormal WBC count,hyperbilirubinemia,or hypoalbuminemia,early drainage(<24 h)reduced the IHM(3.6%vs 33.3%,P=0.004;1.9%vs 5.8%,P=0.031;1.7%vs 5.0%,P=0.019;0%vs 27%,P=0.026;respectively).The IHM was lower in patients with AC combined with hepatic dysfunction,malignant obstruction,or a CCI>3 who had undergone biliary drainage within 48 h(2.6%vs 20.5%,P=0.016;3.0%vs 13.5%,P=0.006;3.4%vs 9.6%,P=0.021;respectively).CONCLUSION Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction,while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade Ⅲ AC.

Presepsin as a biomarker for risk stratification for acute cholangitis in emergency department: A single-center study

BACKGROUND Acute cholangitis is caused by bacterial infection and has high morbidity and mortality risk.The grade of cholangitis can guide clinical treatment from single antibiotic treatment to biliary drainage.With the introduction of white blood cell(WBC)count,C-reactive protein(CRP),and total bilirubin(T-Bil)into the diagnostic criteria and severity grading for acute cholangitis,the diagnosis rate and grading have significantly improved.However,early risk stratification assessments are challenging in the emergency department.Therefore,we hope to find an ideal predictive biomarker for cholangitis grade.Presepsin is a promising biomarker for the early diagnosis,severity,and prognosis of acute bacterial infections.AIM To assess the grading value of presepsin in patients with acute cholangitis.METHODS This clinical study was conducted at the Beijing Friendship Hospital,a 2000-bed teaching hospital with approximately 200000 emergency admissions per year.In this prospective observational study,336 patients with acute cholangitis meeting the Tokyo Guidelines 2018 diagnostic criteria in the emergency department from May 2019 to December 2020 were analyzed.WBC count,CRP,procalcitonin(PCT),presepsin,T-Bil,and blood culture results were collected.The values were compared using the Pearsonχ2 test,Fisher’s exact test,or Mann-Whitney U test.The area under the receiver operating characteristic curve(AUC)of the value was examined using the Delong test.The correlations among the key research indicators were determined using Pearson correlation.RESULTS In total,336 patients were examined,which included 107,106,and 123 patients classified as having mild,moderate,and severe cholangitis,respectively.WBC count,CRP,PCT,presepsin,T-Bil,direct bilirubin,and sequential organ failure assessment scores of moderate and severe cholangitis patients were higher than those of mild cholangitis patients(P=0.000).The AUC of presepsin in predicting moderate acute cholangitis was 0.728,which was higher than that of CRP(0.631,P=0.043)and PCT(0.585,P=0.002),and same as that of WBC count(0.746,P=0.713)and T-Bil(0.686,P=0.361).The AUC of presepsin in predicting severe acute cholangitis was 0.715,which was higher than that of WBC count(0.571,P=0.008),CRP(0.590,P=0.009),PCT(0.618,P=0.024),and T-Bil(0.559,P=0.006).The presepsin levels in the positive blood culture group were higher(2830.8pg/mLvs1987.8pg/mL,P=0.000),and the AUC of presepsin(0.688)proved that it was a good biomarker for predicting positive bacterial culture.CONCLUSION Presepsin can predict positive blood culture in patients with acute cholangitis.It is superior to WBC count,CRP,PCT,and T-Bil for the risk stratification of acute cholangitis.

Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction:experience from a Chinese tertiary hospital

BACKGROUND: The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS: The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS: In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcot’s triad (P【0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS: The TG07 are more reliable than Charcot’s triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.

Acute cholangitis detected ectopic ampulla of Vater in the antrum incidentally: A case report

BACKGROUND The ampulla of Vater is an opening at the confluence of the common bile duct and pancreatic duct.It is located in the second portion of the duodenum.An ectopic papilla of Vater is an anomalous termination.Few cases have been reported.We report the rare case of a man with an ectopic ampulla of Vater in the pylorus.CASE SUMMARY An 82-year-old man had experienced abdominal pain and fever with chills 1 d before his presentation.A computed tomography scan of the abdomen demonstrated dilatation of the common bile duct approximately 2.2 cm in width.Gas retention was found in his intrahepatic ducts.Acute cholangitis with pneumobilia was identified,and he was hospitalized.Esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography disclosed no ampulla of Vater in the second portion of the duodenum.Moreover,a capsule-like foreign body(pharmaceutical desiccant)approximately 1 cm×2 cm in size was found at the gastric antrum and peri-pyloric region.After the foreign body was removed,one orifice presented over the pyloric ring in the stomach,a suspected ectopic ampulla of Vater.Subsequently,sludge in the common bile duct was cleaned,and balloon dilatation was performed.The general condition improved daily.The patient was discharged in a stable condition and followed in our outpatient department.CONCLUSION This case involved an ampulla of Vater in an unusual location.Endoscopic retrograde cholangiopancreatography with balloon dilatation is the main treatment recommended and performed.

Risk factors and incidence of acute pyogenic cholangitis

BACKGROUND: Acute cholangitis varies from mild to severe form. Acute suppurative cholangitis (ASC), the severe form of acute cholangitis, is a fatal disease and requires urgent biliary decompression. Which patients are at a high risk of ASC and need emergency drainage is still unclear. The present study aimed to identify the factors for determining early-stage ASC and distinguishing ASC from acute cholangitis. METHODS: We analyzed 359 consecutive patients with acute cholangitis who had been admitted to the First Affiliated Hospital, Zhejiang University School of Medicine from January 2004 to May 2011. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was carried out in all patients to decompress or clear the stones by experienced endoscopists Clinical and therapeutic data were collected, and univariate and multivariate analyses were performed to identify the potential risk factors of ASC. RESULTS: Of the 359 patients, 1 was excluded because of failure of ERCP drainage. Of the remaining 358 patients with an average age of 62.7 years (range 17-90), 162 were diagnosed with ASC, and 196 with non-ASC. ENBD catheters were placed in 343 patients (95.8%), of whom 182 patients had stones removed at the same time, and plastic stent was placed in 25 patients (7.0%) Clinical conditions were improved quickly after emergency biliary drainage in all patients. Complications were identified in 11 patients (3.1%): mild pancreatitis occurred in 8 patients and hemorrhage in 3 patients. There was no mortality. Univariate analysis showed that several variables were associated with ASC: age, fever, decreased urine output, hypotension, tachycardia abnormal white blood cell count (WBC), low platelet, high C reactive protein (CRP), and duration of the disease. Multivariateanalysis revealed that advanced age, hypotension, abnormal WBC, high CRP, and duration of the disease were independent risk factors for ASC. CONCLUSIONS: This study demonstrates that advanced age, hypotension, abnormal WBC, high CRP, and long duration of antibiotic therapy are significantly associated with ASC. We recommend decompression by ERCP should be carried out in patients as early as possible.