Rescate endoscópico de endoprótesis biliar plástica fistulizante / Endoscopic rescue of a fistulizing biliary plastic stent

55-year-old male with a history of cholecystectomy complicated by perforation of the common bile duct, contained with placement of a plastic biliary stent. He presented several subsequent episodes of recurrent cholangitis secondary to biliary lithiasis and residual benign stenosis of the common bile duct, resolved with the implantation of plastic biliary prostheses. Finally, given the recurrent episodes of cholangitis, it was agreed to perform a hepaticojejunostomy. During the operation, the last implanted stent was not detected, which was identified by CT scan of the abdomen, causing a fistulous tract between the duodenum and the ascending colon. The stent was removed endoscopically, without complications, and the fistulous tract was resolved.(AU)

Infectious complications of non-surgical biliary tract manipulation in paediatric patients. Role of antibiotic prophylaxis / Complicaciones infecciosas de la manipulación no quirúrgica de las vías biliares en pacientes pediátricos. Función de la profilaxis antibiótica

Background: Infections related to non-surgical manipulation of the biliary tract (NSMBT) are common events despite periprocedural antibiotic prophylaxis (PAP). Since June 2017, our local protocol has indicated a 24-h regimen of intravenous piperacillin–tazobactam for this purpose. Objective: We aimed to describe the incidence and characteristics of NSMBT-related paediatric infections, define risk factors for their development, and analyse adherence to our PAP protocol. Materials and methods: Epidemiological, clinical, and microbiological data were collected in consecutive NSMBT procedures performed in paediatric patients (<18 years) in our centre (2010–2019). Results: 113 procedures in 37 patients, median age 4 years (IQR 1–8), were included. Main underlying diseases were biliary atresia (32%) and cancer (14%). Sixty-eight percent had undergone liver transplant and 70% hepaticojejunostomy. In 44 procedures (39%), the intervention was performed during the course of infection and previously prescribed antibiotic treatment was maintained. In the other 69, PAP was specifically indicated for NSMBT; antibiotic adequacy increased from 35% to 100% after June 2017. In total, 32 NSMBT-related infections (28%) occurred, mainly in the first 24h post-procedure (72%); no deaths happened. Causative pathogens were Gram-negative rods (64%), Gram-positive cocci (28%), and Candida spp. (8%). Main related risk factors were hepaticojejunostomy, biliary obstruction, and liver transplant. Conclusions: NSMBT in children entails a significant infection risk, even under antibiotic prophylaxis, being hepaticojejunostomy the main risk factor. Infectious complications mainly occurred immediately after the procedure. After establishing a PAP protocol, 100% of interventions received appropriate prophylaxis, decreasing antibiotic exposure time and potentially, the length of hospital stay.(AU)

Antecedentes: Las infecciones relacionadas con la manipulación no quirúrgica de las vías biliares (MNQVB) son acontecimientos frecuentes, a pesar de la profilaxis antibiótica periprocedimiento (PAP). Desde junio de 2017, nuestro protocolo local indica una pauta de 24 h de piperacilina/tazobactam por vía intravenosa para este fin. Objetivo: El objetivo era describir la incidencia y las características de las infecciones pediátricas relacionadas con la MNQVB, definir los factores de riesgo para su desarrollo y analizar el cumplimiento de nuestro protocolo de PAP. Materiales y métodos: Se recogieron datos epidemiológicos, clínicos y microbiológicos en procedimientos consecutivos de MNQVB realizados en pacientes pediátricos (< 18 años) en nuestro centro (2010-2019). Resultados: Se incluyeron 113 procedimientos en 37 pacientes, con una mediana de edad de 4 años (RIC 1-8). Las principales enfermedades subyacentes fueron atresia biliar (32%) y cáncer (14%). El 68% se había sometido a un trasplante de hígado y el 70% a una hepaticoyeyunostomía. En 44 procedimientos (39%), la intervención se realizó durante el transcurso de la infección y se mantuvo el tratamiento antibiótico recetado previamente. En los otros 69, la PAP estaba indicada específicamente para la MNQVB; la eficacia de los antibióticos aumentó del 35 al 100% después de junio de 2017. En total, se produjeron 32 infecciones relacionadas con la MNQVB (28%), principalmente en las primeras 24 h posteriores al procedimiento (72%); no se produjo ninguna muerte. Los patógenos causantes fueron bacilos gramnegativos (64%), cocos grampositivos (28%) y Candida spp. (8%). Los principales factores de riesgo relacionados fueron la hepaticoyeyunostomía, la obstrucción biliar y el trasplante de hígado.(AU)

Practical management of primary biliary cholangitis

Primary biliary cholangitis (PBC) is a chronic and cholestatic liver disease of autoimmune pathogenesis that mainly affects middle-aged women. Patients show elevated alkaline phosphatase and bilirubin levels as the disease progresses. The main symptoms of the disease are pruritus and fatigue, which interfere with the quality of life of patients. Progressive damage leading to end stage liver disease could require liver transplantation. Despite the efficacy of ursodeoxycholic acid (UDCA), the current standard of care for PBC, up to 40% of patients have an inadequate response to the treatment, requiring a second-line therapy. Obeticholic acid is the only second-line treatment approved for PBC in combination with UDCA in adults with an inadequate response to UDCA, or as monotherapy in patients intolerant to UDCA. Although different clinical guidelines for the diagnosis and management of PBC have been published, PBC is still challenging for many physicians. In this article we briefly review the main characteristics of the disease and include a practical user-friendly algorithm for the diagnosis and management of PBC developed by Spanish PBC experts and based on the European Association for the Study of the Liver recommendations. (AU)

Very urgent endoscopic retrograde cholangiopancreatography is associated with early

Background: endoscopic retrograde cholangiopancreatography (ERCP) is a first-line procedure for biliary drainage in patients with acute cholangitis, and there are no studies focused on very urgent ERCP within several hours of hospital arrival. This study aimed to elucidate the use of very urgent ERCP for non-severe acute cholangitis.Methods: this retrospective observational study included patients with non-severe acute cholangitis who underwent ERCP between April 2011 and June 2020 in our institution. Patients were stratified into three groups based on time to ERCP after hospital arrival: very urgent (≤ 3 hours), urgent (3-24 hours) and elective (> 24 hours). The primary outcome was length of hospital stay (LOS).Results: the study cohort included 291 patients, 168 males (57.7 %), with a median age of 76 (interquartile range, 70-83) years. In all, 47, 196 and 48 patients underwent very urgent, urgent and elective ERCP, respectively. Median LOS in the very urgent, urgent, and elective groups was 12, 14, and 15 days, respectively (Kaplan-Meier method). A shorter LOS was associated with earlier ERCP (log-rank trend test, p = 0.04). The rates of readmission within 30 days of discharge and of adverse events were not significantly different among the three groups. By multivariate analysis, very urgent ERCP was associated with a significantly earlier discharge than urgent and elective ERCP (HR, 0.71, p = 0.04 and HR, 0.47, p < 0.01, respectively). In addition, age ≥ 75 years, pancreatitis, albumin ≤ 2.8 g/dL and two or more ERCP procedures were associated with a significantly longer LOS (HRs < 1, p < 0.05). (AU)

Clinical characteristics, aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stent / Características clínicas, etiología y factores de riesgo de mortalidad/recidiva de la colangitis bacteriana aguda en pacientes con y sin stent biliar

Objectives: Acute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers. Methods: We performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence. Results: Two hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18–8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38–.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55–6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p=0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11–0.77]). Conclusions: Clinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.(AU)

Objetivos: La colangitis aguda es una de las complicaciones más frecuentes en los pacientes portadores de stents biliares. El objetivo de nuestro estudio es analizar las características demográficas y clínicas, así como el perfil microbiológico y la evolución de los pacientes con colangitis bacteriana aguda, comparándolos en función de si eran o no portadores de stents biliares. Métodos: Se realizó un análisis retrospectivo de todos los pacientes consecutivos mayores de 18 años con un stent colocado en nuestro centro entre 2008 y 2017. Los comparamos con nuestra cohorte prospectiva de pacientes con diagnóstico de colangitis bacteriana aguda. El criterio principal de valoración fue la mortalidad a los 30 días. Los criterios secundarios de valoración fueron la curación clínica el día 7, la mortalidad a los 14 días y la recidiva a los 90 días. Resultados: Se analizaron 273 pacientes, incluyendo 156 en el grupo relacionado con el stent (RS) y 117 en el grupo no relacionado con el stent (NRS). Los pacientes con colangitis RS eran más jóvenes, con más enfermedades concomitantes y con una mayor intensidad de la infección. Las cepas aisladas más frecuentes fueron Escherichia coli y Klebsiellapneumoniae. Enterococcus spp. fue la tercera cepa aislada más frecuente en el grupo RS, pero no fue frecuente en los pacientes NRS, en los que E. coli fue el microorganismo más prevalente. El choque septicémico (HR: 3,44; IC del 95%: 1,18-8,77), el tratamiento empírico inadecuado (HR: 2,65; IC del 95%: 1,38-7,98) y la neoplasia avanzada (HR: 2,41; IC del 95%: 1,55-6,44) fueron factores de riesgo de mortalidad a los 30 días independientes. La tasa de recidiva a los 90 días fue significativamente más elevada en aquellos pacientes con colangitis RS (29 frente al 13%; p=0,016) y el reemplazo del stent se asoció a una menor tasa de recidiva (HR: 0,38; IC del 95%: 0,11-0,77).(AU)

¿Está justificado el retrasplante hepático en la era actual? / Is Liver Retransplantation Justified in the Current Era?

Introducción: El retrasplante hepático (ReTH) es una indicación de TH controvertida. Nuestro objetivo fue determinar la tasa de ReTH y las indicaciones, morbilidad, mortalidad posoperatoria y supervivencia actuarial del paciente retrasplantado en nuestra serie. Métodos: Estudio retrospectivo de una serie prospectiva de 1.645 pacientes trasplantados entre 1984 y 2018. Se analizan los resultados según el tipo de ReTH (precoz vs. tardío), periodo de estudio e indicaciones. Resultados: Hemos realizado 150 ReTH en 140 pacientes. La tasa de ReTH fue de 9%. El 30% (45) de los ReTH fueron precoces, siendo tardíos el otro 70% (105). Las causas más frecuentes fueron: colangitis isquémica (27%), trombosis de la arteria hepática (19%), fallo primario del injerto (15%) y recidiva de la cirrosis por virus de la hepatitis C (VHC) (15%). La duración de la cirugía (395 vs. 270 min; p = 0,001), tiempo de isquemia (435 vs. 390 min; p = 0,005) y necesidad transfusional (8 vs. 5 CH; p = 0,034) fue mayor en los casos de ReTH tardío, mientras que la mortalidad posoperatoria (10 vs. 20%; p = 0,01) fue mejor en los casos de ReTH tardío. La supervivencia actuarial a uno y cinco años fue de 71% y 58%, respectivamente, con una mejoría significativa en la última década (80% y 64%). Por otra parte, la supervivencia en los casos de ReTH por colangitis isquémica es superior que otras indicaciones (78 vs. 51%; p = 0,02). Conclusiones: El retrasplante es complejo y está asociado a una elevada morbimortalidad. Sin embargo, los resultados han mejorado en los últimos años por lo que su indicación está justificada. (AU)

Introduction: Liver retransplantation (LRT) is a controversial indication. Our aim was to evaluate the rate of LRT at our institution, and to analyze its indications and short- and long-term results. Methods: We conducted a retrospective study of a prospectively collected database, including 1645 LT from 1984 to 2018. Results have been analyzed depending on type of LRT (early vs late), study period and indications. Results: We performed 150 LRT in 140 patients. The LRT rate was 9%. Of these, 45 LRT were early (30%), and the other 70% were late LRT. The main indications were: ischemic cholangitis (27%), arterial thrombosis (19%), primary non-function (15%), and HCV recurrence (15%). Mean surgery duration (395 vs. 270 min; P = .001), cold ischemia time (435 vs. 390 min; P = .005) and transfused units required (8 vs. 5 RBC; P = .034) were higher in cases of late LRT. Postoperative mortality (10 vs. 20%; P = .01) was better in cases of late LRT. One- and 5-year actuarial survival rates were 71% and 58%, respectively, which were significantly better during the last decade (80% and 64%). Five-year actuarial survival for ischemic cholangitis is better than other indications, such as recurrence of HCV (78 vs. 51%; P = .02). Conclusions: Liver retransplantation is complex and associated with high morbidity and mortality. However, indications and long-term results have improved during recent years. Therefore, LRT is justified. (AU)

Colangitis crónicas: diagnóstico diferencial y papel de la resonancia magnética / Chronic cholangitides: differential diagnosis and role of MRI

Las colangitis crónicas idiopáticas son un grupo de enfermedades hepatobiliares, de probable origen autoinmune, que suelen ser asintomáticas en sus estadios iniciales y pueden evolucionar hacia cirrosis hepática. La sospecha se establece al encontrar elevación de las enzimas de colestasis en analíticas de sangre. Entre las colangitis idiopáticas, la más frecuente es la colangitis esclerosante primaria, asociada a la enfermedad inflamatoria intestinal y que conlleva una incidencia aumentada de neoplasias hepatobiliares y del tubo digestivo. Es importante establecer el diagnóstico diferencial con la colangitis asociada a IgG4, la colangitis biliar primaria y colangitis secundarias, puesto que el manejo terapéutico es diferente. La colangiopancreatografía por resonancia magnética (CPRM) es la mejor prueba para la valoración de la vía biliar intrahepática y extrahepática, y el estudio de RM proporciona información sobre el hígado y el resto de los órganos abdominales. Un adecuado protocolo de CPRM y el conocimiento de los distintos hallazgos colangiográficos característicos de cada entidad son esenciales para alcanzar un diagnóstico correcto

The idiopathic chronic cholangitides comprise a group of hepatobiliary diseases of probable autoimmune origin that are usually asymptomatic in the initial stages and can lead to cirrhosis of the liver. Elevated cholestatic enzymes on blood tests raise suspicion of these entities. Among the idiopathic cholangitides, the most common is primary sclerosing cholangitis, which is associated with inflammatory bowel disease and with an increased incidence of hepatobiliary and digestive tract tumors. It is important to establish the differential diagnosis with IgG4-associated cholangitis, primary biliary cholangitis, and secondary cholangitides, because the therapeutic management is different. Magnetic resonance cholangiopancreatography (MRCP) is the best test to evaluate the intrahepatic and extrahepatic biliary tract, and MRI also provides information about the liver and other abdominal organs. An appropriate MRCP protocol and knowledge of the different findings that are characteristic of each entity are essential to reach the correct diagnosis

Hepatopatías autoinmunitarias / No disponible

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Cholangiohydatidosis: an uncommon cause of acute cholangitis

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Efficacy of ursodeoxycholic acid combined with prednisolone and immunosuppressant triple therapy in the treatment of refractory primary biliary cholangitis / Eficacia del ácido ursodesoxicólico combinado con prednisolona y triple terapia inmunosupresora en el tratamiento de la colangitis biliar primaria refractaria

Background and AIM: To explore the efficacy treatment regimen in refractory PBC. METHODS: Triple treatment including ursodeoxycholic acid, prednisolone and immunosuppressant was prescribed to 47 refractory patients. Biochemistries, immune parameters, non-invasive liver fibrosis assessments were measured during follow-up. RESULTS: Triple therapy resulted in significant decrease in ALP, GGT, ALT, AST, TBIL, ALB, IgG, IgM, APRI, FIB-4 and S-INDEX. The biochemical cumulative normalization rates of ALP and other biochemical parameters were higher in long-term follow-up. Poor outcome was observed in patients with lower ALB, higher TBIL, PT, sp100 positivity and advanced liver pathology at baseline. Osteoporosis and bone fracture were observed in 15% patients. CONCLUSIONS: Triple therapy is associated with marked decrease and normalization of ALP and other parameters. ALB, TBIL, PT, sp100 and pathology were related with poor outcome. Osteoporosis should be closely monitored

ANTECEDENTES Y OBJETIVO: Explorar el régimen de tratamiento de eficacia en PBC refractario. MÉTODOS: Se prescribió un tratamiento triple que incluyó ácido ursodesoxicólico, prednisolona e inmunosupresor a 47 pacientes refractarios. Las bioquímicas, los parámetros inmunes, las evaluaciones no invasivas de fibrosis hepática se midieron durante el seguimiento. RESULTADOS: La triple terapia resultó en una disminución significativa de ALP, GGT, ALT, AST, TBIL, ALB, IgG, IgM, APRI, FIB-4 y S-INDEX. Las tasas de normalización bioquímica acumulada de ALP y otros parámetros bioquímicos fueron mayores en el seguimiento a largo plazo. Se observó un resultado deficiente en pacientes con ALB más bajo, TBIL más alto, PT, positivo de SP100 y enfermedad hepática avanzada al inicio del estudio. La osteoporosis y la fractura ósea se observaron en el 15% de los pacientes. CONCLUSIONES: La triple terapia se asocia con una marcada disminución y normalización de ALP y otros parámetros. ALB, TBIL, PT, SP100 y la enfermedad se relacionaron con un mal resultado. La osteoporosis debe estar bajo estrecha supervisión

A rare case of acute cholangitis after endoscopic ampullectomy

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Endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy in patients with surgically altered gastrointestinal anatomy

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) allows a diagnostic and therapeutic evaluation of pancreatobiliary diseases. However, the procedure in patients with surgically altered gastrointestinal anatomy represents a technical challenge. OBJECTIVE: to report the diagnostic and therapeutic outcome of device-assisted enteroscopy (DAE) ERCP in patients with a surgically altered gastrointestinal anatomy. METHODS: a prospective cohort of patients with a history of surgically altered gastrointestinal anatomy undergoing DAE-ERCP in a referral center was used. A double-balloon enteroscope was used to reach the papillary area or the bilio-enteric anastomosis. The clinical and endoscopic characteristics, and technical, diagnostic and therapeutic success were described. Clinical and endoscopic differences were evaluated according to diagnostic success, as well as the biochemical response in those patients with therapeutic success. RESULTS: ninety-six procedures were included in the study in 75 patients. Roux-en-Y hepaticojejunostomy (RYHJ) was the main surgical anatomy (82.3%) and cholangitis was the main indication for ERCP (49%). Diagnostic success was obtained in 69.8% of the participants. Of these, therapeutic success was obtained in 83.6% (overall success 58.3%). Cases with a diagnostic success had a higher frequency of cholangiography compared to those without diagnostic success (94% vs 0%, p < 0.001), as well as a lower probability of a failed cannulation (1.5% vs 100%, p < 0.001). A significant improvement was observed in patients with a therapeutic success in bilirubin, transaminases and alkaline phosphatase levels (p < 0.05). CONCLUSIONS: ERCP by means of double-balloon enteroscopy is a useful technique in patients with a surgically altered gastrointestinal anatomy, in whom access to the bile duct is required. However, these procedures are very challenging and diagnostic and therapeutic success where achieved in up to 60% of cases

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Colangitis bacteriana complicada con sangrado por pseudoaneurisma hepático / No disponible

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