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      Acute Bacterial Cholangitis

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          Abstract

          Background

          Acute bacterial cholangitis for the most part owing to common bile duct stones is common in gastroenterology practice and represents a potentially life-threatening condition often characterized by fever, abdominal pain, and jaundice (Charcot's triad) as well as confusion and septic shock (Reynolds' pentad).

          Methods

          This review is based on a systematic literature review in PubMed with the search items ‘cholangitis’, ‘choledocholithiasis’, ‘gallstone disease’, ‘biliary infection’, and ‘biliary sepsis’.

          Results

          Although most patients respond to empiric broad-spectrum antibiotic treatment, timely endoscopic biliary drainage depending on the severity of the disease is required to eliminate the underlying obstruction. Specific recommendations have been derived from the Tokyo guideline working group consensus 2006 and its update in 2013, albeit poorly evidence-based, providing a comprehensive overview of diagnosis, classification, risk stratification, and treatment algorithms in acute bacterial cholangitis.

          Conclusion

          Prompt clinical recognition and accurate diagnostic workup including adequate laboratory assessment and (aetiology-oriented) imaging are critical steps in the management of cholangitis. Treatment is directed at the two major interrelated pathophysiologic components, i.e. bacterial infection (immediate antimicrobial therapy) and bile duct obstruction (biliary drainage). As for the latter, transpapillary endoscopic drainage by stent or nasobiliary drain and/or same-session bile duct clearance, depending on individual disease severity, represent first-line treatment approaches.

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          Most cited references63

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          Complications of endoscopic biliary sphincterotomy.

          Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
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            Natural history of asymptomatic and symptomatic gallstones.

            Review of the sparse literature on the prognosis of asymptomatic and mildly symptomatic gallstones reveals a diversity of methods, definitions, and groups of patients studied, which makes it difficult to draw conclusions. It appears that serious symptoms and complications develop in about 1% to 2% of patients with asymptomatic gallstones annually, with fewer complications developing in later years than in years soon after gallstones are discovered. In patients with stones with mild symptoms, rates of the development of complications are perhaps a little higher, about 1% to 3% per year. In patients who are initially mildly symptomatic, cholecystectomy for severe symptoms probably is undertaken in 6% to 8% per year in the early years, decreasing with longer follow-up. Other than symptoms, no factors related to prognosis have been established. Acute cholecystitis is the most common severe complication of gallstones. Based on follow-up studies, obstructive jaundice, cholangitis, pancreatitis, and cancer of the gallbladder are infrequent complications. Risk of subsequent colon cancer should not ordinarily be a factor when cholecystectomy is considered. Analyses of cost-effectiveness have not demonstrated substantial differences in life expectancy between patients with asymptomatic gallstones who undergo immediate open cholecystectomy compared with watchful waiting.
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              Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study.

              The necessity for drainage of both liver lobes in tumors arising at the biliary bifurcation is controversial. The aim of this study was to compare the outcome of unilateral versus bilateral drainage in patients with biliary obstruction at the hilum. One hundred fifty-seven consecutive patients with primary cholangiocarcinoma, gallbladder cancer, or periportal lymph node metastases were randomly allocated to unilateral (group A) or bilateral (group B) hepatic duct drainage. In intention-to treat analysis, group A had a significantly higher rate of successful endoscopic stent insertion than group B (88.6% vs. 76.9%, p = 0.041). Group B had a significantly higher rate of complications than group A (26.9% vs. 18.9%, p = 0.026) because of the higher rate of early cholangitis (16.6% vs. 8.8%, p = 0.013). In per-protocol analysis the rate of successful drainage, complications, and mortality did not differ between the two groups. Median survival did not differ between the two groups but was significantly different for patients with cholangiocarcinoma and those with gallbladder cancer versus patients with metastatic tumors (p = 0.0247). The insertion of more than one stent would not appear justified as a routine procedure in patients with biliary bifurcation tumors.
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                Author and article information

                Journal
                Viszeralmedizin
                Viszeralmedizin
                VIM
                Viszeralmedizin
                S. Karger Verlag für Medizin und Naturwissenschaften GmbH (Wilhelmstrasse 20A, P.O. Box · Postfach · Case postale, D–79095, Freiburg, Germany · Deutschland · Allemagne, Phone: +49 761 45 20 70, Fax: +49 761 4 52 07 14, information@karger.de )
                1662-6664
                1662-6672
                June 2015
                11 June 2015
                1 June 2016
                : 31
                : 3
                : 166-172
                Affiliations
                Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
                Author notes
                *Dr. med. Vincent Zimmer, Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421 Homburg/Saar, Germany, vincent.zimmer@ 123456uks.eu
                Article
                vim-0031-0166
                10.1159/000430965
                4569195
                26468310
                474b1733-1986-4e2b-9de2-a72cebd638d4
                Copyright © 2015 by S. Karger GmbH, Freiburg
                History
                Page count
                Figures: 2, Tables: 3, References: 65, Pages: 7
                Categories
                Review Article

                cholangitis,endoscopic retrograde cholangiography,sepsis,gallstone disease

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