[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.

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 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.

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.

[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.

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.

A case of infected biloma due to spontaneous intrahepatic biliary rupture.

A "biloma" is a loculated collection of bile located outside of the biliary tree. It can be caused by traumatic, iatrogenic or spontaneous rupture of the biliary tree. Prior reports have documented an association of biloma with abdominal trauma, surgery and other primary causes, but spontaneous bile leakage has rarely been reported. A spontaneous infected biloma, without any underlying disease, is a very rare finding. We recently diagnosed a spontaneous infected biloma by abdominal computed tomography and sonographically guided percutaneous aspiration. The patient was successfully managed with percutaneous drainage and intravenous antibiotics. We report here a case of infected biloma caused by spontaneous rupture of the intrahepatic duct, and review the relevant medical literature.

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.

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.

[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.

Helicobacter genus DNA fragments are commonly detectable in bile from patients with extrahepatic biliary diseases and associated with their pathogenesis.

Several Helicobacter species are known to colonize the biliary tract in animals and have been identified in the gallbladder bile of a high proportion of Chilean patients with gallbladder cancer. In this study, we tried to examine the presence of Helicobacter species in the bile to know their participation in the development of extrahepatic biliary diseases. DNA was extracted from 57 bile samples from 30 patients with benign biliary diseases (cholecystolithiasis and choledochocystolithiasis), 6 malignant biliary diseases (gallbladder cancer and common bile duct cancer), and 21 nonbiliary diseases. The presence of Helicobacter genus-, H. pylori-, H. hepaticus-, and H. bilis-specific 16S rRNA genes, the H. pylori urease A gene, and the H. pylori 26K protein gene in the bile was determined by PCR and sequencing analysis. Helicobacter genus DNA (shorter amplicons, 400 bp) was statistically frequently detected in biles from 53% (16/30) and 86% (5/6) of benign and malignant biliary diseases, compared with 9% (2/21) of nonbiliary diseases, but longer amplicons (1200 bp) were not detectable in any samples. The H. pylori urease A gene (nested amplicon) was also frequently found in bile, whether benign, malignant, or control, though neither H. pylori 16S rRNA nor the 26K protein gene was detectable in any bile samples. H. bilis-16S rRNA genes were detectable in only two cases. H. hepaticus was not detectable in any samples. DNA fragments of Helicobacter species other than H. pylori, H. hepaticus, and H. bilis are commonly detectable in the bile of patients with extrahepatic biliary diseases, whether benign or malignant, implying that the Helicobacter genus may be directly or indirectly involved in the pathogenesis of these diseases.

Biliary tract infection in patients with acute biliary pancreatitis.

BACKGROUND: The presence of infective microorganisms in the bilio-pancreatic tract is believed to be important in both the onset and outcome of acute biliary pancreatitis. In this study, the characteristics of bile colonization or infection in human pancreatitis were investigated in order to optimize prophylactic antibiotic therapy. METHODS: In 174 patients, 22 clinical and biological factors were recorded prospectively on admission and compared with the bacteriological findings at the time of surgery. RESULTS: There was a significant difference between patients with negative or positive bile cultures in six parameters: Age (57.7 +/- 1.7 vs. 68.5 +/- 1.5 years, p < 0.001), serum concentrations of glucose (132 +/- 4 vs. 149 +/- 6 mg/dL, p < 0.02) and alanine aminotransferase (ALT) (304 +/- 28 vs. 226 +/- 25 IU/L, p < 0.05) and hematocrit (43.4 +/- 0.4% vs. 41.7 +/- 0.5%, p < 0.05), Glasgow pancreatitis score (1.58 +/- 0.11 vs. 1.97 +/- 0.10, p < 0.01) and APACHE II score (6.20 +/- 0.38 vs. 7.82 +/- 0.35, p < 0.005). The prediction of the presence of bacteria in bile by each of these individual parameters, however, was of variable accuracy. From 82 patients with positive bile cultures, a total of 150 microorganisms were isolated, including 66 gram-positive aerobes, 66 gram-negative facultative anaerobes, 15 obligate anaerobes, and three fungi. The most common organisms were Escherichia coli (20.6%), followed by enterococci (18%) and streptococci (15.3%). CONCLUSION: Patients with acute biliary pancreatitis who manifest abnormalities of one or more of the above-mentioned risk factors are more likely to have positive bile cultures. Whether such patients might benefit from early antibiotic therapy directed against both gram-negative bacilli and gram-positive cocci needs to be determined.

Pneumocystis carinii infection presents as common bile duct mass biopsied by fine-needle aspiration.

This paper describes a case of Pneumocystis carinii (PC) presenting as a common bile duct intraluminal mass in an HIV-infected 30-yr-old homosexual man. In fine-needle aspiration smears, exuberant vascular proliferation associated with multinucleated giant-cell reactions was found within the granular exudate of PC.

[Detection of Helicobacter pylori by polymerase reaction in bile samples from gallbladder and bile stones]. / Deteccion del Helicobacter pylori por reacción en cadena de la polimerasa en muestras de bilis de pacientes con litiasis vesicular y coledociana.

Some papers report helicobacter pylori existence in bile from surgical specimens obtained during gallbladder or bile ducts surgery. The aim of this work was search by PCR, H. Pylori presence in bile specimens from patients suffering of gallbladder stones or by bile ducts stones. Bile samples were obtained by gallbladder punction during cholecystectomy in 26 patients, 19 of them with gallbladder stones and 7 also with gallbladder stones and bile duct stones. Age ranged from 22-69 years old, median 49.6 years old. Samples were sent to specialized biomolecular laboratory to perform PCR techniques. Two of 26 patients (7.6%) had positive reaction for the presence of DNA of H. Pylori in bile samples. Our research suggest that DNA of H. Pylori can be founded in bile samples patients with gallbladders and duct stones in Argentina.

Detection of Helicobacter DNA in bile from bile duct diseases.

Several species of Helicobacter colonize the hepatobiliary tract of animals and cause hepatobiliary diseases. The aim of this study is to investigate Helicobacter found in the biliary tract diseases of humans. Thirty-two bile samples (15 from bile duct cancer, 6 from pancreatic head cancer, and 11 from intrahepatic duct stone) were obtained by percutaneous transhepatic biliary drainage. Polymerase chain reaction analysis using Helicobacter specific urease A gene and 16S rRNA primers, bile pH measurement, and Helicobacter culture were performed. Helicobacter DNA was detected in 37.5%, and 31.3% by PCR with ureA gene, and 16S rRNA, respectively. The bile pH was not related to the presence of Helicobacter. The cultures were not successful. In conclusion, Helicobacter can be detected in the bile of patients with bile duct diseases. The possibility of pathogenesis of biliary tract diseases in humans by these organisms will be further investigated.

Detection del Helicobacter pylori por reacción en cadena de la polimerasa en muestras de bilis de pacientes con litiasis vesicular y coledociana / Detection of Helicobacter pylori by polimerase reaction in bile samples from gallblader and bile stones

Algunos trabajos describen la presencia de H. Pylori en muestras de bilis obtenidas durante la cirurgía por litiasis en vesícula y vías biliares. El objetivo de este trabajo, ha sido detectar la presencia del ADN del H. Pylori por medio de la Reacción en cadena de la Polimerasa (PCR) en muestras de bilis de pacientes con litasis vesicular y/o de vías biliares. Las muestras de bilis fueron obtenidas de 26 pacientes, 19 con litiasis vesicular y 7 con litiasis vesicular y coledociana, con edades comprendidas entre 22 a 69 años, media de 49,6 años, por punción de vesicular durante la colecistectomia. Las muestras fueron tratadas adecuadamente y preparadas para su investigación por PCR. 2 de 26 casos (7,6 por ciento) fueron positivos para la presencia en bilis del DNA del H. Pylori. Nuestro trabajo sugiere que el DNA del H P puede ser encontrado en muestras de bilis de pacientes portadores de litiasis biliar en la Argentina.

Acute emphysematous cholecystitis associated with pneumobilia: a case report.

This report describes a rare case of acute emphysematous cholecystitis with pneumobilia in the common bile duct. The patient was a 66-year-old woman with a part history of diabetes mellitus, and operations for gastric and breast carcinoma. The chief complaint was pain in the right hypochondrium with severe right hypochondrial tenderness and distention of the gallbladder detected on examination. Laboratory tests showed leukocytosis, marked elevation of CRP, jaundice, liver dysfunction, and hyperglycemia. Gas was detected in the gallbladder on plain abdominal X-rays and CT scans of the abdomen, and a small amount of gas was also observed in the common bile duct. On the day of admission, percutaneous transhepatic gallbladder drainage (PTGBD) was carried out under ultrasound guidance, and Clostridium perfingens and E. coli were detected in the bile. Imaging after PTGBD showed no cystic duct obstruction. On the 12th day after PTGBD, cholecystectomy and choledochotomy with primary closure were performed. The postoperative course was good and the patient was discharged on the 15th day after surgery.

Anaerobic culture yield in interventional radiologic drainage procedures.

PURPOSE: This study was designed to determine the yield of anaerobic cultures from percutaneous radiologic drainage procedures. PATIENTS AND METHODS: Anaerobic culture results in 317 patients from June 1992 to May 1994 were retrospectively examined. Anaerobic specimens were placed in specially designed anaerobic culture tubes and not blood culture media. Patients had undergone the following procedures: percutaneous nephrostomy (105 patients), biliary drainage (65 patients), and abdominal abscess drainage (147 patients). Aerobic culture results were tabulated in those patients with positive anaerobic cultures. RESULTS: Overall, 10% of patients (n = 32) had positive anaerobic cultures (Bacteroides species, n = 25; Clostridium, n = 6; other organisms, n = 4). Anaerobes were isolated in 13% (n = 19) of abdominal abscess drainages, 8% (n = 8) of nephrostomy drainages, and 8% (n = 5) of biliary drainages. Aerobic isolates were present in 78% (n = 25) of patients with anaerobic infection. CONCLUSION: The yield for anaerobic cultures varies for different types of percutaneous drainage procedures from 8% to 13%. When isolated, anaerobic bacteria are frequently mixed with aerobic bacteria. Anaerobic culture usage is recommended with abdominal abscess and biliary drainages. Anaerobic bacterial cultures are not recommended for percutaneous nephrostomy unless the patient has a urinary tract malignancy or has undergone urinary instrumentation.