A retrospective clinical and microbial analysis of 32 patients with bilomas.

BACKGROUND: Bilomas are defined collections of bile fluids mainly caused by iatrogenic injuries of the bile duct system. Owing to the infrequency of this disease, studies addressing bilomas are rare. METHODS: By using an endoscopic database, this retrospective study identified 32 patients with bilomas treated between 2004 to 2015, in order to analyse aetiology, clinical presentation, spectrum of pathogens, and resolution rate of bilomas. RESULTS: 65.6% of the study population (21/32) developed bilomas after surgery and 21.9% (7/32) after endoscopic retrograde cholangiography (ERC). Icterus, fever, and abdominal pain were the leading symptoms. 93.9% (46/49) of microbiological bile cultures revealed a positive microbiology. The predominant microorganisms were the group of Enterobacteriaceae (43.0%, 52/121), followed by Enterococcus spp. (32.2%, 39/121), and Candida spp. (9.1%, 11/121). Multiresistant bacteria like Enterobacteriaceae were isolated from one quarter of all patients. Single or multimodal treatment resulted in an overall complication rate of 4.8% (9/188). Clinical follow-up analysis showed a complete resolution rate of 78.3% for interventional therapy and 80% in the non-interventional group. CONCLUSIONS: Pathogen spectrum of bilomas mainly comprises the group of Enterobacteriacae and Enterococcus spp., with a high proportion of multiresistant bacteria. Different interventional approaches are available for biloma drainage, which seem to be safe and effective for most patients. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015208 , retrospectively registered.

Biliary Paracoccidioidomycosis: An Unusual Infection Simulating Malignant Neoplasm.

Paracoccidioidomycosis is a systemic granulomatous disease caused by the dimorphic fungus Paracoccidioides brasiliensis and is restricted to Latin America. It normally affects lungs, skin and lymph nodes. Abdominal organs are usually not involved. In rare cases paracoccidioidomycosis may simulate neoplasm. Herein we describe our experience with four cases of paracoccidioidomycosis mimicking cholangiocarcinoma. To the best of our knowledge, this is the largest case series on this subject produced in English. Paracoccidioidomycosis must be considered as a differential diagnosis of cholangiocarcinoma, especially in individuals who come from endemic areas.

[A consensus statement on the standardized application of antibacterial agents in biliary tract surgery (2019)].

The standardized application of antibacterial agents in the treatment of biliary tract diseases is of great significance.On the basis of international and domestic guidelines and consensuses, combining with the actual situation of Chinese biliary tract infection, Study Group of biliary Tract Surgery in Chinese Society of Surgery of Chinese Medical Association and Enhanced Recovery After Surgery Committee of Chinese Research Hospital Association and Editorial Board of Chinese Journal of Surgery organized experts to make recommendations which adopted a problem-oriented approach on the severity grade of biliary tract infection, the protocol of specimen examination, the use of antibiotics, the indication of drug withdrawal, the agents application strategy of drug-resistant bacteria infection and special situation to guide surgeons getting the accurate judgement of the severity of biliary tract infection and the formulation of standard protocols for the use of antibacterial agents on the premise of following the bacteriological and drug resistance monitoring information.

Inflammation and the Gut-Liver Axis in the Pathophysiology of Cholangiopathies.

Cholangiocytes, the epithelial cells lining the bile ducts, represent the unique target of a group of progressive diseases known as cholangiopathies whose pathogenesis remain largely unknown. In normal conditions, cholangiocytes are quiescent and participate to the final bile volume and composition. Following exogenous or endogenous stimuli, cholangiocytes undergo extensive modifications of their phenotype. Reactive cholangiocytes actively proliferate and release a set of proinflammatory molecules, which act in autocrine/paracrine manner mediating the cross-talk with other liver cell types and innate and adaptive immune cells. Cholangiocytes themselves activate innate immune responses against gut-derived microorganisms or bacterial products that reach the liver via enterohepatic circulation. Gut microbiota has been implicated in the development and progression of the two most common cholangiopathies, i.e., primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC), which have distinctive microbiota composition compared to healthy individuals. The impairment of intestinal barrier functions or gut dysbiosis expose cholangiocytes to an increasing amount of microorganisms and may exacerbate inflammatory responses thus leading to fibrotic remodeling of the organ. The present review focuses on the complex interactions between the activation of innate immune responses in reactive cholangiocytes, dysbiosis, and gut permeability to bacterial products in the pathogenesis of PSC and PBC.

EUS-guided drainage of hepatic abscess and infected biloma using short and long metal stents (with videos).

BACKGROUND: Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent. OBJECTIVE: We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma. DESIGN: Retrospective case series. SETTING: Single tertiary referral medical center. PATIENTS: We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital. INTERVENTIONS: EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent. MAIN OUTCOME MEASUREMENTS: Technical success, clinical success, and adverse event. RESULTS: The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success rates of EUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days). LIMITATIONS: Small sample size and no control group. CONCLUSIONS: EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma.

Isolated hepatobiliary cryptococcosis manifesting as obstructive jaundice in an immunocompetent child: case report and review of the literature.

The majority of patients with symptomatic cryptococcosis have an underlying immunocompromising condition. In the absence of coexisting immunocompromising condition, Cryptococcus neoformans is rarely considered in the differential diagnosis of obstructive jaundice that occurs in children with hilar masslike lesion. Here, we report a 5-year-old boy without immunoglobulin or lymphocyte abnormalities who developed a hepatobiliary infection with C. neoformans. Ultrasonography and computed tomography showed dilatation of the bilateral intrahepatic bile ducts and a low-attenuated mass in the hepatic hilum. Microscopic examination of tissue samples revealed abundant numbers of encapsulated yeast cell suggestive of C. neoformans. After 4 months of antifungal therapy (liposomal amphotericin B for 2 weeks and oral fluconazole for 3 months), the disease was effectively controlled. Unnecessary operation could be avoided by an early and accurate diagnosis. By sharing our experience, we suggest hepatobiliary surgeons and gastroenterologists should have a suspicion of this unusual entity to make earlier diagnosis and treatment.

Treatment of bacteriobilia decreases wound infection rates after pancreaticoduodenectomy.

BACKGROUND: Although mortality following pancreaticoduodenectomy is decreasing, postoperative morbidity remains high. It was hypothesized that culture-directed treatment of bacteriobilia would decrease the incidence of infectious complications following pancreaticoduodenectomy. METHODS: In a retrospective study of 197 pancreaticoduodenectomy patients, those in the control group (n = 128, 2005-2009) were given perioperative prophylactic antibiotics, whereas those in the treatment group (n = 69, 2009-2011) were continued on antibiotics until intraoperative bile culture results became available. Patients with bacteriobilia received 10 days of antibiotic treatment, which was otherwise discontinued in patients without bacteriobilia. Various complication rates were compared using Fisher's exact test for categorical variables, Wilcoxon rank sum test for ordinal variables, and a two-sample t-test for continuous variables. RESULTS: Demographics, comorbidities, baseline clinical characteristics, and intraoperative and postoperative variables were similar between the two groups. There were higher incidences of elevated creatinine (19% versus 4%; P = 0.004) and preoperative hyperglycaemia (18% versus 7%; P = 0.053) in the control group. Fewer patients in the control group underwent preoperative biliary stenting (48% versus 67%; P = 0.017) and intraperitoneal drains were placed at the time of resection more frequently in the control group (85% versus 38%; P < 0.001). Bacteriobilia was found in 59% of patients. Treatment of bacteriobilia was associated with a decrease in the rate of postoperative wound infections (12% in the control group versus 3% in the treatment group; P = 0.036) and overall complication severity score (1 in the control group versus 0 in the treatment group; P = 0.027). CONCLUSIONS: Prolonged antibiotic therapy for bacteriobilia may decrease postoperative wound infection rates after pancreaticoduodenectomy. A randomized prospective trial is warranted to provide evidence to further support this practice.

A novel combination regimen for the treatment of refractory bacteremia due to multidrug-resistant Pseudomonas aeruginosa in a liver transplant recipient.

Both bacteremia and biliary cast syndrome are serious post-transplant complications in liver transplant recipients. In the setting of increasing drug resistance in the current era, management of infections caused by multidrug-resistant (MDR) bacteria has proven challenging. We present a case of a liver transplant recipient who developed biliary cast syndrome and intractable MDR Pseudomonas bacteremia that failed to resolve with conventional antimicrobial therapy and which was finally controlled by a novel combination regimen of colistimethate, doripenem, and tobramycin. Future studies validating the clinical efficacy of this combination strategy are warranted.

[Microbiologic study of the bile culture and antimicrobial susceptibility in patients with biliary tract infection].

BACKGROUND/AIMS: Bacterial infection of biliary tract may cause severe inflammatory response or sepsis. An immediate bile culture and appropriate antibiotic administration are important to control the biliary tract infection. The objective of the study was to identify organisms in bile and the features of antibiotic susceptibility in patients with biliary tract infection. METHODS: We retrospectively reviewed the clinical records of 212 patients whose bile had been cultured for variable biliary tract diseases at Inje University Ilsan Paik Hospital from Jan. 2000 to Feb. 2007. Bile samples were obtained from percutaneous transhepatic biliary drainage (PTBD, n=89), percutaneous transhepatic gallbladder drainage (PTGBD, n=14) or endoscopic naso-biliary drainage (ENBD, n=49). RESULTS: The overall positive rate of bile culture was 71.7% (152 cases). The organisms cultured were Escherichia coli (25.0%), Enterococcus spp. (13.4%), Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) in decreasing order. Effective antibiotics for Gram-negative organisms were amoxicillin/clavulanic acid, amikacin, imipenem, and piperacillin/tazobactam in order of effectiveness. Of the cultured blood samples from 160 patients, fifty (31.2%) showed positive bacterial growth. The organisms isolated from blood were similar to those found in the bile. CONCLUSIONS: A broad spectrum penicillin/beta-lactamase inhibitor is a recommendable antimicrobial for empirical treatment for biliary tract infection. However, Gram-positive bacteria such as Enterococcus spp. or methicillin-resistant Staphylococcus aureus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

Epidemiology, determinants, and management of AIDS cholangiopathy: A review.

Diseases of the liver and biliary tree have been described with significant frequency among patients with human immunodeficiency virus (HIV), and its advanced state, acquired immunodeficiency syndrome (AIDS). Through a variety of mechanisms, HIV/AIDS has been shown to affect the hepatic parenchyma and biliary tree, leading to liver inflammation and biliary strictures. One of the potential hepatobiliary complications of this viral infection is AIDS cholangiopathy, a syndrome of biliary obstruction and liver damage due to infection-related strictures of the biliary tract. AIDS cholangiopathy is highly associated with opportunistic infections and advanced immunosuppression in AIDS patients, and due to the increased availability of highly active antiretroviral therapy, is now primarily seen in instances of poor access to anti-retroviral therapy and medication non-compliance. While current published literature describes well the clinical, biochemical, and endoscopic management of AIDS-related cholangiopathy, information on its epidemiology, natural history, and pathology are not as well defined. The objective of this review is to summarize the available literature on AIDS cholangiopathy, emphasizing its epidemiology, course of disease, and determinants, while also revealing an updated approach for its evaluation and management.

The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery.

BACKGROUND: The merit of pre-operative biliary drainage in managing hepatic, biliary or pancreatic patients remains unclear with previous studies demonstrating significant increases in bacterobilia. AIMS: To establish if pre-operative biliary drainage was associated with (i) a change in bacterial flora, (ii) post-operative sepsis and (iii) to ascertain if a modification of antibiotic prophylaxis was warranted. METHODS: Data were collected on 331 patients undergoing hepatic, biliary or pancreatic surgery for malignant obstruction between August 2000 and June 2005. Microbiological data from intra-operative bile, post-operative wounds, blood cultures, urine and sputum were analysed. All episodes of pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stenting and percutaneous drainage were documented. RESULTS: One hundred and sixty two patients had ERCP prior to surgery and 154 had surgery only. In comparison to patients who had surgery alone stented patients had significantly increased rates of bacterobilia (40 vs. 85%) and fungobilia (8 vs. 34%, both P < 0.001). Pre-operative biliary drainage significantly increased post-operative sepsis, wound infections and prolonged in-patient stay (P < 0.05). The most common organisms cultured were coliforms and enterococcus with percutaneous transhepatic cholangiography (PTC) highly significant for the development of MRSA sepsis. CONCLUSIONS: Pre-operative biliary drainage is associated with a high incidence of bacterobilia and fungal colonization. Pre-operative biliary drainage should be utilized selectively, with modification of antibiotic prophylaxis according to patient characteristics.

Bacterial culture results from liver, gallbladder, or bile in 248 dogs and cats evaluated for hepatobiliary disease: 1998-2003.

BACKGROUND: Information is lacking on the prevalence and susceptibility patterns of bacterial isolates in dogs and cats with suspected hepatobiliary disease. OBJECTIVES: To characterize the prevalence, identity, and antimicrobial susceptibility of common hepatobiliary isolates from such patients. ANIMALS: Dogs and cats presented to the University of Wisconsin-Madison Veterinary Medical Teaching Hospital for which samples of bile, gallbladder, or liver were submitted for culture from 1998 to 2003, including 190 dogs (192 culture episodes) and 58 cats (61 culture episodes). METHODS: Cases were identified from the microbiology laboratory database. Data from patient medical records were extracted, including the history of antimicrobial administration, the presence of fever, the results of CBC and serum biochemistry, the presence of biliary obstruction or hepatobiliary inflammation, and the results of aerobic and anaerobic bacterial cultures and aerobic antimicrobial susceptibilities. RESULTS: Biliary cultures yielded a significantly higher percentage of positive results overall (30% [18 of 60]) than did hepatic cultures (7% [15 of 215]). In patients with cholecystitis, 62% (8 of 13) had positive biliary cultures. In patients with hepatic inflammation, 23% (7 of 30) had positive bile cultures, whereas only 6% (6 of 103) had positive hepatic cultures. Escherichia coli, Enterococcus spp., Bacteroides spp., Streptococcus spp., and Clostridium spp. were the most common true-positive isolates. More than 80% of Enterobacteriaceae were susceptible to ciprofloxacin or aminoglycosides, with only 30-67% susceptible to first-generation aminopenicillins and cephalosporins. Liver samples obtained by surgery or laparoscopy were more likely to yield positive cultures than those obtained by percutaneous needle biopsy.

Hepatobiliary and pancreatic tuberculosis: a two decade experience.

BACKGROUND: Isolated hepatobiliary or pancreatic tuberculosis (TB) is rare and preoperative diagnosis is difficult. We reviewed our experience over a period two decades with this rare site of abdominal tuberculosis. METHODS: The records of 18 patients with proven histological diagnosis of hepatobiliary and pancreatic tuberculosis were reviewed retrospectively. The demographic features, sign and symptoms, imaging, cytology/histopathology, procedures performed, outcome and follow up data were obtained from the departmental records. The diagnosis of tuberculosis was based on granuloma with caseation necrosis on histopathology or presence of acid fast bacilli. RESULTS: Of 18 patients (11 men), 11 had hepatobiliary TB while 7 had pancreatic TB. Two-thirds of the patients were < 40 years (mean: 42 yrs; range 19-70 yrs). The duration of the symptoms varied between 2 weeks to 104 weeks (mean: 20 weeks). The most common symptom was pain in the abdomen (n = 13), followed by jaundice (n = 10), fever, anorexia and weight loss (n = 9). Five patients (28%) had associated extra-abdominal TB which helped in preoperative diagnosis in 3 patients. Imaging demonstrated extrahepatic bile duct obstruction in the patients with jaundice and in addition picked up liver, gallbladder and pancreatic masses with or without lymphadenopathy (peripancreatic/periportal). Preoperative diagnosis was made in 4 patients and the other 14 were diagnosed after surgery. Two patients developed significant postoperative complications (pancreaticojejunostomy leak 1 intraabdominal abscess 1) and 3 developed ATT induced hepatotoxicity. No patient died. The median follow up period was 12 months (9-96 months). CONCLUSION: Tuberculosis should be considered as a differential diagnosis, particularly in young patients, with atypical signs and symptoms coming from areas where tuberculosis is endemic and preoperative tissue and/or cytological diagnosis should be attempted before labeling them as hepatobiliary and pancreatic malignancy.

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

[The distribution and pathogen of bacteria infection in patients after liver transplantation].

OBJECTIVE: To find out the epidemiology of bacteria infection after orthotopic liver transplantation (OLT). METHOD: Postoperative bacteria infection of 451 OLT cases were retrospectively analyzed. RESULT: Bacteria infection were detected in 239 OLT cases, and the infection rate was 52.9%. Sum up to 304 bacilli lines were separated from all above cases. Among them, the detectable Gram-positive bacilli (G(+)) accounted for 59.9% (182/304), while Gram-negative bacilli (G(-)) accounted for 40.2% (122/304). The impressionable organ were respiratory tract and bile duct, which occupying 81.5% (248/304) and 15.1% (46/304) among all infective cases respectively. The main infected strain were G(+) bacteria in respiratory tract, account for 65.3%; while G(-) bacteria were mainly in bile duct, account for 60.9%. There was significant difference between each other (P = 0.018). CONCLUSIONS: The bacteria infection rate was high after OLT, and the main infected strain was the G(+) bacteria. Most fo them were the opportunistic pathogenic bacteria and the antibiotic multi-resistant bacteria. The bacteria category was significantly related to the infected tissue, according to which we could adopt corresponding antibacterial approach.

[Bacteriobilia: a non-resolved problem]. / Bacteriobilia: un problema sin resolver.

Bile duct is usually sterile, and the isolating of microorganisms (bacteriobilia) has been related to some factors, such as age, biliary drainage before pancreatic surgery or bile duct stones. Gramnegative strains remain the most frequent pathogens, especially Escherichia coli. Among grampositives Enterococcus spp should be mentioned. Currently, there is controversy about whether the presence of bacteriobilia has an impact on unfavorable outcome of biliary disease or surgical procedures or mortality rates, with complications such as surgical site infections or bacteremia. In high-risk patients, such as immunosuppressed or those underwent pancreaticoduodenectomy, bile duct cultures performed routinely, even if there are not clinical data of infection, could be necessary in order to start antibiotic treatment or to reduce its spectrum.

Bacterobilia may trigger the development and severity of pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Although biliary infection (bacterobilia) is considered a risk factor for infectious complications after pancreatoduodenectomy, the association between bacterobilia and postoperative pancreatic fistula has remained unclear. The aim of this study is to investigate the impact of bacterobilia on the development of postoperative pancreatic fistula following pancreatoduodenectomy. METHODS: We conducted a retrospective review of the patients who underwent pancreatoduodenectomy between November 2010 and July 2014. Intraoperative bile cultures and cultures of the peripancreatic drainage fluid on postoperative days 1 and 3 were investigated in all patients. RESULTS: Of 264 patients, 151 (57%) patients had a positive intraoperative bile culture. The incidence of grade B/C postoperative pancreatic fistulas (by the international definition) was greater in patients with a positive intraoperative bile culture than in those with a negative intraoperative bile culture (38% vs 25%, P = .025). A multivariate analysis revealed that a positive intraoperative bile culture (odds ratio, 2.60; P = .002) and a body mass index of ≥22 kg/m(2) (odds ratio, 2.18; P = .008) were independent risk factors for grade B/C postoperative pancreatic fistulas. Among the 151 patients with a positive intraoperative bile culture, the microorganism(s) isolated from the bile was detected in the drainage fluid of 100% of the patients on postoperative day 1 and in 88% of patients on postoperative day 3. CONCLUSION: Bacterobilia was found to be a risk factor for grade B/C postoperative pancreatic fistulas, and bacteria from the infected bile may be the source of the grade B/C postoperative pancreatic fistulas.

Septicemia with Streptococcus pseudopneumoniae: report of three cases with an apparent hepatic or bile duct association.

Streptococcus pseudopneumoniae was described in 2004 as a new human pathogen, acknowledged in a range of clinical infections typically associated to the respiratory tract. This report demonstrates that S. pseudopneumoniae has the potential to cause invasive infection. In blood cultures from three patients, growth of an atypical Streptococcus pneumoniae (non-capsular, non-serotypeable, optochin susceptible under ambient atmosphere and bile-intermediately soluble) was recovered. All three patients had a history of a haematological disease (myelodysplastic syndrome and multiple myeloma) and an apparent origin of infection related to the liver or bile duct. All isolates were genome sequenced and subsequently identified as S. pseudopneumoniae by multi-locus sequence analysis (MLSA). Multi-locus sequence typing (MLST) based on the S. pneumoniae scheme revealed unknown sequence types and the antibiogram and resistome revealed no antibiotic resistance.

[Role of bacteriobilia in postoperative complications]. / Papel de la bacteriobilia en las complicaciones postoperatorias.

OBJECTIVE: At present there is a controversy regarding the impact of positive bile cultures on morbidity and mortality rates, and on the incidence of readmissions in patients with biliar disease. The aim of this study was to evaluate the role of bacteriobilia in postoperatory infections, mortality or readmissions in these patients. METHODS: The information was obtained from all patients with bile cultures admitted to Hospital Universitario Marqués de Valdecilla (Santander, Spain) from January to December 2011. Clinical, epidemiological and microbiological data and laboratory findings were analyzed. The patients were followed for two years. RESULTS: One hundred and fifty-two patients (65% men) were included. Mean age was 67 years (SD= 15 years). The most frequent diagnoses were acute cholecystitis (79%) and cholangitis (8%). Laparoscopic cholecystectomy was performed in 42% of patients, open cholecystectomy in 45% and percutaneous cholecystostomy in 8%. Bacteriobilia was present in 83 patients (55%). The most frecuent microorganisms isolated were Escherichia coli (31%), Enterococcus faecium (13%) and Klebsiella pneumoniae (13%). The initial antimicrobial agent was a carbapenem in 62 patients (44%) and piperacillin-tazobactam in 28 (18%). There were 39 postoperative infections (26%), 21 readmissions (14%) and 17 patients died during admission (11%). The presence of microorganisms in bile cultures was not a statistically significant predictor of neither complications nor readmissions. CONCLUSIONS: Intra-operative bile cultures would allow guide early appropriate antibiotic treatment use in case of infection, or empiric antimicrobial therapy, however there was no correlation between bacteriobilia and postoperative infections, length of stay, mortality or readmissions.