Assessing the clinical utility of abdominal computed tomography in sepsis patients with unknown origin: A retrospective cohort study.

Early identification of the sources of infection in emergency department (ED) patients of sepsis remains challenging. Computed tomography (CT) has the potential to identify sources of infection. This retrospective study aimed to investigate the role of CT in identifying sources of infection in patients with sepsis without obvious infection foci in the ED. A retrospective chart review was conducted on patients with fever and sepsis visiting the ED of Linkou Chang Gung Memorial Hospital between July 1, 2020 and June 30, 2021. Data on patient demographics, vital signs, clinical symptoms, underlying medical conditions, laboratory results, administered interventions, length of hospital stay, and mortality outcomes were collected and analyzed. Of 218 patients included in the study, 139 (63.8%) had positive CT findings. The most common sources of infection detected by CT included liver abscesses, acute pyelonephritis, and cholangitis. Laboratory results showed that patients with positive CT findings had higher white blood cell and absolute neutrophil counts and lower hemoglobin levels. Positive blood culture results were more common in patients with positive CT findings. Additionally, the length of hospital stay was longer in the group with positive CT findings. Multivariate logistic regression analysis revealed that hemoglobin levels and positive blood culture results independently predicted positive CT findings in patients with fever or sepsis without an obvious source of infection. In patients with sepsis with an undetermined infection focus, those presenting with leukocytosis, anemia, and elevated absolute neutrophil counts tended to have positive findings on abdominal CT scans. These patients had high rates of bacteremia and longer lengths of stay. Abdominal CT remains a valuable diagnostic tool for identifying infection sources in carefully selected patients with sepsis of undetermined infection origins.

A new method to estimate the histological stage of primary biliary cholangitis.

OBJECTIVE: To analyze the diagnostic efficacy of the periportal hypoechoic band (PHB) in the histological stage of patients with primary biliary cholangitis (PBC). METHODS: We prospectively included 77 cases of PBC pathologically or clinically confirmed, and high-frequency ultrasound (HFUS) measurements of the PHB were performed in all included patients. Ludwig staging system of histopathology was used as the gold standard. RESULTS: The width of the PHB was positively correlated with histological staging (r = 0.844, p < 0.001). By area under the receiving operating characteristic curve (AUROC), the best cutoff value for PHB for advanced stage (≥ stage 3) was 2.4 mm (AUROC: 0.934; 95%CI: 0.841-0.981) and 0.93 for sensitivity, and 0.91 for specificity, the concordance rates of PHB vs. liver biopsy was 90.3%. The correct rate for early-stage PBC was 87.9% and for the progressive stage was 93.1%. After multi-factor regression analysis, the PHB (OR = 1.331, CI = 1.105-1.603, p = 0.003) and total bilirubin (OR = 1.156, CI = 1.041-1.285, p = 0.007) were independent influencing factors for progressive PBC. CONCLUSIONS: Measurement of the PHB to assess advanced PBC is a simple and effective method. This method may complement current methods for the histological staging assessment of patients with PBC. REGISTRATION: Clinical trial registration: ChiCTR 2000032053, 2020/04/19. CLINICAL RELEVANCE STATEMENT: The measurement of periportal hypoechoic band (PHB) provides a simple and easy assessment of the degree of disease progression in patients with PBC and provides an important clinical reference in predicting the histological staging of PBC from an ultrasound perspective. KEY POINTS: • The PHB is correlated with histological staging in the patient with PBC. • The area under the ROC curves of PHB for detecting advanced stage (≥ stage 3) were 0.934 and 0.93 for sensitivity, and 0.91 for specificity, the concordance rates of PHB vs. liver biopsy was 90.3%. The application of PHB can better assess the advanced PBC. • Measurement of the PHB to assess advanced PBC is a simple and effective method that can significantly reduce the need for liver biopsy.

A multi-institutional study designed by members of Tokyo Guidelines (TG) Core Meeting to elucidate the clinical characteristics and pathogenesis of acute cholangitis after bilioenteric anastomosis and biliary stent insertion with a focus on biliary obstruction: Role of transient hepatic attenuation difference (THAD) and pneumobilia in improving TG diagnostic performance.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

Ultrasound imaging findings in primary biliary cholangitis.

BACKGROUND: Our study aimed to analyze the characteristics of ultrasound images corresponding to each histological stage of primary biliary cholangitis (PBC). METHODS: We prospectively analyzed 75 confirmed cases of PBC and used liver biopsy as the gold standard to determine the disease stage. RESULTS: The typical ultrasound images of patients with PBC were characterized by a thickening of the portal vein wall (PVW) and periportal hypoechoic band (PHB) width with increasing histological stages, and significant increases in the left hepatic lobe diameter (LHLD) in stage II (by 64.0%) and stage III (by 69.2%). PHB width (r = 0.857, p < 0.001), PVW thickness (r = 0.488, p < 0.001), and spleen area (r = 0.8774, p < 0.001) were positively correlated with the histological stage. Significant changes were noted in the liver surface, echo texture, and edge between different stages. The areas under the receiver operating characteristic curve of composite indicators were 0.965 for predicting progressive PBC(≥ stage 2), and 0.926 for predicting advanced PBC(≥ stage 3). CONCLUSIONS: The ultrasound imaging characteristics of patients with PBC varied according to the histological staging. LHLD, PVW thickness, and PHB width were significantly correlated with the histological stage. A combination of high- and low-frequency ultrasound imaging can provide relevant cues regarding the degree of PBC progression and important clinical reference values. The application of all the ultrasound image findings as the composite indicators can better predict progressive and advanced PBC, providing important clinical reference values.

Endoscopy in Gallstone Pancreatitis.

The root cause for biliary pancreatitis is a transient impediment of the outflow of secretion from the pancreatic duct due to gallstones and sludge obstructing the ampulla of Vater. Based on meta-analyses and recent studies, clear recommendations can be formulated when and when not to perform an ERC in patients with biliary pancreatitis. ERC is indicated urgently in patients with biliary pancreatitis and concomitant cholangitis. Urgent ERC is not indicated in patients with predicted mild or severe biliary pancreatitis without cholangitis, even when stones or sludge are proven on EUS imaging.

The association between sonographic common bile duct dilatation and outcomes in emergency department patients with cholangitis.

BACKGROUND: The presentation of the patient with acute cholangitis (AC) ranges from mild illness to life-threatening shock. Therefore, prompt diagnosis and treatment are critical. Abdominal ultrasound (US) is the imaging of choice to locate bile duct dilatation. Other modalities include abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVES: To determine whether sonographic common bile duct dilatation in emergency department (ED) patients with AC predicts outcomes including sepsis, hospital length of stay (LOS), admission to the intensive care unit (ICU), time to ERCP, and mortality. METHODS: Electronic medical records of all patients hospitalized in a tertiary care medical center between July 2012-February 2021 with a discharge diagnosis of cholangitis were assessed. Patients were dichotomously classified as CBD dilated or CBD non-dilated based on ultrasound. Dilation was defined as CBD larger than 6 mm in patients younger than 60 or larger than 6 mm + 1 mm per decade in patients over 60. RESULTS: The study included 271 patients- 172 with CBD dilation versus 99 without. Mean LOS was 9.92 days for those with a dilated CBD versus 13.4 days without. The mean time to ERCP was 4.26 days for those with a dilated CBD versus 6.56 days without. Sepsis, mortality, and ICU admission were scarce and there was no statistically significant difference between the cohorts. CONCLUSION: Patients with a dilated CBD per the abdominal US performed during the patient's ED stay, underwent ERCP earlier, and were hospitalized fewer days than patients without CBD dilation.

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.

Doppler ultrasonography blood flow changes of the hepatic artery in liver transplants complicated with cholangitis.

PURPOSE: Cholangitis after liver transplantation may lead to bile duct necrosis. Early diagnosis is essential to prevent graft loss. We aimed to investigate cholangitis related hepatic arterial Doppler ultrasonography findings in liver transplants. METHODS: Patients complicated with biopsy proven cholangitis in grafts were prospectively evaluated. Vascular complications were excluded. Doppler ultrasonography parameters including hepatic arterial diameter, resistive index, volume flow, and portal vein maximum velocity were measured twice: first during cholangitis and after full recovery. Data of two groups were compared using paired samples t test and Mann-Whitney U test. RESULTS: The mean hepatic arterial volume flow, resistive index, and diameter of 33 patients complicated with cholangitis was observed to decrease after recovery from 0.356 to 0.273 L/min (p = 0.007), from 0.64 to 0.60 (p < 0.001) and from 4.9 to 4.4 mm (p < 0.001), respectively. Portal vein maximum velocity alteration was not statistically significant (p = 0.6). CONCLUSION: Ultrasound follow-ups after liver transplantation can give us the clue of cholangitis initiation through some altering hepatic arterial Doppler parameters. Even though these are nonspecific findings that can also be observed in vascular complications, baseline Doppler data should be saved for future comparison and considered to prevent biliary associated graft loss.

Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones.

BACKGROUND: The revised American Society for Gastrointestinal Endoscopy (ASGE) guideline 2019 provides the high-risk criteria for suspected common bile duct stones (CBDSs). AIMS: To evaluate CBDS detection rates during endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients with suspected CBDSs based on the ASGE guideline 2019. METHODS: This multicenter retrospective study included 1100 consecutive patients who underwent ERCP for suspected CBDSs with any high-risk criteria based on the revised ASGE guideline 2019: Criterion 1, CBDSs on imaging; Criterion 2, clinical ascending cholangitis; and Criterion 3, total bilirubin exceeding 4 mg/dL and dilated common bile duct on imaging. We compared CBDS detection rates during ERCP based on individual and combined high-risk criteria. RESULTS: The CBDS detection rates of patients who met any of the criteria, only Criterion 1, and Criteria 2 or 3 were 86.0% (946/1100), 93.4% (113/121), and 50.0% (106/212), respectively. In patients who met Criteria 1 and 2, 1 and 3, 2 and 3, and all criteria, CBDSs were confirmed during ERCP in 95.1% (490/515), 96.2% (25/26), 55.3% (26/47), and 98.4% (186/189), respectively. The CBDS detection rate during ERCP of patients with at least Criterion 1 significantly exceeded that of patients without at least Criterion 1 [95.7% (814/851) vs. 51.0% (132/259), respectively, P < 0.001]. CONCLUSIONS: Patients with CBDS visualization on imaging have very high CBDS detection rates during ERCP. However, performing ERCP on patients with only clinical predictors, such as cholangitis and dilated CBD with total bilirubin exceeding 4 mg/dL, often results in unnecessary ERCP.

The role and timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: A nationwide analysis.

BACKGROUND/PURPOSE: The role and optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis without cholangitis (ABPwoC) remains unclear. Using a large national database, we aimed to examine hospitalization outcomes of patients with ABPwoC as a function of the performance and timing of ERCP. METHODS: This was a retrospective study of adult patients with ABPwoC utilizing the National Inpatient Sample from 2016-2017. Patients who underwent inpatient ERCP were stratified into performance: within 24, 24-48, 48-72, and >72 h of hospital admission. The primary outcome was all-cause inpatient mortality as a function of the performance and timing of ERCP; secondary outcomes, including healthcare utilization, were assessed. Multivariate modeling was used to adjust for potential confounders. Statistical analyses were conducted using STATA, version 16.0. RESULTS: Of the 70 030 patients with ABPwoC, 31.37% underwent inpatient ERCP. Performance (aOR: 0.6, p < .05), but not timing (aOR: 0.98, p = .9), of inpatient ERCP was associated with significantly lower all-cause inpatient mortality. Urgent ERCP (within 24 h) was associated with shorter hospital length of stay, lower charges and cost, and less need for pancreatic drainage procedures, while ERCP within 72 h was associated with less frequent intensive care unit admission (all p < .05). DISCUSSION: Based on this large, nationwide analysis, inpatient ERCP for ABPwoC is associated with lower all-cause mortality. ERCP within 24 and 72 h, though not associated with lower mortality, are associated with multiple improved clinical outcomes, including lower healthcare charges and costs.

Validation of Tokyo guidelines 2018 for safety and mortality benefit from urgent ERCP in acute cholangitis across different age groups.

BACKGROUND: The 2018 Tokyo Guidelines (TG18) recommend urgent endoscopic biliary drainage based on acute cholangitis (AC) severity. Therefore, we evaluated the safety and mortality benefits of urgent endoscopic retrograde cholangiopancreatography (ERCP) in different age groups. METHODS: Using International Classification of Diseases-10 (ICD-10) codes, we sampled adult AC patients from National Inpatient Sample. TG18 definition of cholangitis severity was used to identify patients with severe and nonsevere (mild or moderate) AC. Age categories were 18-64, 65-79, and 80 and above. Multivariate linear or logistic regression was used as appropriate. We used Stata, version 14.2, to perform analyses considering two-sided p < .05 as statistically significant. RESULTS: Among 137 100 patients, there were 93 365 (68.09%) patients with nonsevere cholangitis and 43 735 (31.91%) patients with severe cholangitis. Urgent ERCP (within 24 h) resulted in decreased mortality in all age groups for both severe and nonsevere AC. Post-sphincterotomy bleeding was more common in patients ≥80 years of age, whereas post-ERCP acute cholecystitis was more common in patients 65-79 years. The rates of post-ERCP pancreatitis, bile duct perforation, and duodenal perforation did not differ among the age groups. In addition, there were no differences in the rate of sedation-related complications between different age groups who underwent urgent ERCP. CONCLUSION: This study demonstrates the mortality benefit from urgent ERCP for AC in different age groups and describes the safety of performing urgent ERCP in patients of various ages. Therefore, we recommend that urgent ERCP be performed according to the TG18 guidelines regardless of age.

Intense FDG Uptake in the Common Bile Duct Post-ERCP Mimics Acute Infectious Cholangitis.

In patients with obstructive pancreatitis due to choledocholithiasis, endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care. ERCP-induced inflammation or infection of the common bile duct (i.e., cholangitis) is a rare complication with a high mortality rate in severe cases. We report an unusual case of incidental findings of intense FDG uptake in the common bile duct one month post-ERCP without clinical features of acute cholangitis, indicative of inflammation of CBD associated with or exaggerated by ERCP.

Usefulness of hepatobiliary scintigraphy for predicting late complications in patients with choledochal cysts.

PURPOSE: Hepatobiliary scintigraphy is a minimally invasive imaging method that evaluates bile flow dynamics. At our hospital, it has been performed for postoperative evaluation of patients with choledochal cysts (CC). This study evaluated the usefulness of biliary scintigraphy for predicting late complications in patients with CCs. METHODS: The study included pediatric patients with CC who underwent surgery at Chiba University Hospital from 1978 to 2020, followed by postoperative biliary scintigraphy and subsequent radiologic evaluation. The patients were divided into two groups according to the presence or absence of "biliary cholestasis" on biliary scintigraphy. RESULTS: The study included 108 patients, with a median age at surgery of 2 years and 11 months. The median follow-up period was 5203 days, with 11 hepatolithiasis cases and 8 cholangitis cases. No patients had cholangiocarcinoma. Twelve patients were considered to have "cholestasis" following biliary scintigraphy evaluation. There was no significant difference in the occurrence of hepatolithiasis between the cholestasis and non-cholestasis groups (p = 0.47), but cholangitis was significantly more common in the cholestasis group (p = 0.016). CONCLUSION: Biliary cholestasis on postoperative hepatobiliary scintigraphy was a risk factor for cholangitis in patients with CCs. These particular patients should be monitored carefully.

Post mortem computed tomography as a complementary tool for diagnosing cholangiohepatitis in a giant panda (Ailuropoda melanoleuca).

A geriatric female giant panda developed grave signs of illness and was diagnosed with suspected hepatobiliary tract obstruction or other severe hepatic disease such as advanced cholangiohepatitis. The giant panda was euthanized and post mortem computed tomography was performed prior to necropsy. Common bile duct obstruction at the major duodenal papilla by a mineral attenuating calculus causing dilatation of common bile and gallbladder with concurrent multiple areas of liver abscess were detected by postmortem computed tomography. These were confirmed with gross necropsy. This is the first case report of common bile duct obstruction by mineral calculus with concurrent severe cholangiohepatitis in a giant panda.