Bacteriology and antimicrobial susceptibility in biliary tract disease: an audit of 10-year's experience

Cholelithiasis, choledocholithiasis and hepatolithiasis are common biliary tract diseases. These diseases may cause severe infection and/or sepsis. In addition to surgical treatments, prompt administration of appropriate antibiotic is important to control the biliary tract infection. The purpose of this study is to illustrate the bacteriology in biliary tract disease and provide information for antibiotic choices. From Jan 1991 to Aug 2000, 1394 patients including gallbladder (GB) stones, common bile duct (CBD) stones, intrahepatic duct (IHD) stones, GB polyps and biliary malignancy were subjects for this retrospective study. The overall positive rate of bile culture is 36% in this study while it was 25%, 66%, 67% and 9% for GB stones, CBD stones, IHD stones and biliary malignancy, respectively. A significantly higher (p = 0.001) positive culture rate was found for GB stones with acute cholecystits (47%) compared with that without inflammation (17%). Similarly, the culture rate for hepatolithiasis with acute cholangitis was higher than that without cholangitis (75% vs 51%, p = 0.011). Long-term external biliary drainage in biliary malignancy increased the risk of bacterial culture rate. For gallstone diseases, the most common organisms cultured were Gram negative bacteria (74%), in which Escherichia coli (36%) and Klebsiella (15%) were most commonly found, followed by Gram positive (15%) bacteria such as Enterococcus (6%), Staphylcoccus (3%), Streptococcus (2%). Bacteroides (5%) and Clostridium (3%) were occasionally found anaerobes (9%). Polymicrobial infection was encountered in 19%, 31% and 29% for patients with GB stones, CBD stones and IHD stones, respectively; frequency of mixed aerobic and anaerobic infection was 7%, 12% and 9%. In the current study, ampicillin in combination with sulbactam and aminoglycoside is still a suggestive empirical therapy. Antibiotic treatment should be adjusted based on later bacteriological cultures and clinical condition.     

Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance]

Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance.Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The aim of our prospective study was to investigate the presence and degree of biliary bacterial colonization by means of bile aspiration during ERCP in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient. In addition, analysis of risk factors was performed that would predispose to the development of cholangitis.80 patients with clinical and laboratory evidence of biliary obstruction underwent ERCP with initial aspiration of bile via the cannulation catheter.This material was used to culture aerobic and anaerobic bacteria and determine the colony count/ml bile, followed by identification of each species and antibiotic resistance testing. The minimal inhibitory concentration for Levofloxacin, Ciprofloxacin, Piperacillin, Ampicillin, Ceftriaxone, Imipenem, Gentamycin und Metronidazole was determined. Immediately after the ERCP or if the body temperature (after ERCP) rose to > 38 degrees C blood cultures were obtained.In 45 (56 %) patients biliary colonization with bacteria could be identified (56 %). In 20 patients a single isolate was cultured, in 25 cases mixed infection was present. A total of 83 species were isolated. The most common bacteria were E. coli, Enterococcus and Klebsiella. 9.6 % of all isolates were obligatory anaerobes. In 9 of 80 patients bloodcultures tested positive for bacterial growth (rate of bacteremia: 11.3 %). 10 patients had acute cholangitis clinically before ERCP, 13 patients developed signs of infection after ERCP.Statistically significant factors contributing to the risk of infection were age of the patient, the clinical condition of the patient before ERCP and the biliary colony count.Patients with development of infection after ERCP showed a significantly higher incidence of bacterial colonization of the biliary tree and a higher colony count.In all bacterial species Imipenem (4.5 %) or Levofloxacin (2.2 %) exhibited the lowest rate of in-vitro resistance.Based on these data, the implementation of Levofloxacin in combination with anaerobic coverage is advantageous as a calculated therapy for patients with acute cholangitis.     

Bacteriological study of choledochal bile in patients with common bile duct stones, with or without acute suppurative cholangitis

Acute suppurative cholangitis is a serious complication in extrahepatic biliary tract obstruction. Bacteriological studies have shown that in these patients the bile cultures usually present several kinds of bacteria, especially Gram-negative aerobic bacteria such as E. coli and Klebsiella sp. The mortality rate in our patients with common bile duct stones and acute suppurative cholangitis is enhanced 5- to 10-fold. The aim of the present study was to analyse the bacterial properties of choledochal bile in a large number of patients with common bile duct stones, with or without acute suppurative cholangitis, and to determine the sensitivity of the isolated bacteria to several antibiotics used in clinical practice. The greatest sensitivity of the bacteria isolated from the common bile duct was seen for aminoglycosides (gentamicin and amikacin) and for cephalosporins, especially of the third generation (cefotaxime, ceftazidime, ceftriaxone and cefoperazone). Ampicillin showed a low sensitivity rate. The appropriate selection of the antibiotics used in acute suppurative cholangitis depends not only on the concentration of the antibiotic in the bile; a high plasma concentration is even more important to control the septic manifestations. A high excretion to the bile can affect the intestinal flora, leading to diarrhea (e. g. with cefoperazone). Ampicillin has been giving contradictory results in respect of bile and plasma concentrations. Gentamicin attains 30-40% of the plasma concentration in the bile, but persists for as long as 8 hours with excellent sensitivity and clinical efficacy. Amikacin reaches 44% of the plasma concentration with a very high sensitivity (96%).(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of dominant stenoses in bacterial infections of bile ducts in primary sclerosing cholangitis

OBJECTIVE: Primary sclerosing cholangitis (PSC) is characterized by progressive fibrotic inflammation and strictures of the biliary system. We studied the role of dominant stenoses in bacterial biliary infections and the effect of routine antibiotic administration with cholangiography. DESIGN: A prospective clinical trial without blinding or randomization. SETTING: The endoscopy unit in a university hospital. PARTICIPANTS: Fifty patients with PSC entered and finished the study. INTERVENTIONS: A total of 103 endoscopic retrograde cholangiographies (ERC) was performed in 37 PSC patients with dominant stenosis and 13 controls with PSC but no dominant stenosis. After selective cannulation of the bile duct, bile samples were obtained during each procedure. All patients received systemic antibiotic treatment with ciprofloxacin for one week after ERC. RESULTS: Enteric bacteria were detected in the bile specimens of 15 out of 37 PSC patients (40.5%) with dominant stenosis but never in the absence of dominant stenosis (P=0.004). Positive cultures for enteric bacteria were associated with elevated serum C-reactive protein, high leukocyte counts in bile (P<0.05) and the deterioration of liver function assessed by increasing bilirubin levels during the follow-up period lasting a median of 7 months (P=0.06). Despite the high rate of susceptibility in vitro, ciprofloxacin treatment eradicated enteric bacteria in only two out of 12 cases. CONCLUSION: Bacterial infection of the bile ducts with dominant stenosis is a frequent finding and may play a role in the progression of PSC. Short-course antibiotic treatment is not very effective in eradicating acteria from the bile ducts.     

不同程度急性胆管炎患者的胆汁细菌培养及药敏分析

目的调查不同程度急性胆管炎患者的胆汁细菌培养及药敏状况,为临床合理用药及预防提供数据指导。方法对2010年4月-2014年4月收治的230例急性胆管炎患者的资料进行回顾性分析,采用VITEK2 Compact微生物仪对患者胆汁进行细菌种类鉴定及药物敏感性试验。计量资料组间比较采用方差分析,计数资料采用χ2检验。结果 230例患者中172例患者胆汁培养存在细菌,阳性率为74.78%(172/230);共检出病原菌237株,其中革兰氏阳性菌135株,占56.96%,以肠球菌属、金黄色葡萄球菌为主;革兰氏阴性菌96株,占40.51%,以铜绿假单胞菌、大肠杆菌、肺炎杆菌为主;真菌6株,占2.53%,以酵母菌为主。轻度胆管炎与重度胆管炎细菌感染率比较差异具统计学意义(χ2=4.58,P=0.028)。革兰氏阴性菌是轻、中度急性胆管炎的主要细菌类别,多重细菌感染是重度急性胆管炎细菌感染的主要形式。细菌对万古霉素、亚胺培南和阿米卡星等的敏感率较高。结论革兰氏阳性菌是急性胆管炎的主要病原菌,应早期介入治疗,及时病原菌检测及药敏试验,为临床治疗提供准确方向。     

Risk factors for recurrent cholangitis after initial hepatolithiasis treatment

GOALS: To elucidate the risk factors that can affect the rate of cholangitis after hepatolithiasis treatment. BACKGROUND: Hepatolithiasis is prevalent in East Asia and causes long-term complications. Recurrent cholangitis is one of its most serious complications and can lead to biliary stricture, liver cirrhosis, and even cholangiocarcinoma. However, little is known about the risk factors associated with cholangitis. STUDY: The clinical records of 193 patients with hepatolithiasis who had been newly diagnosed and treated were reviewed. The mean follow-up was 56 months (1-242 months). RESULTS: Cumulative cholangitis rates were 25.0% at 3 years and 37.0% at 5 years. By multivariate analysis, cholangitis was associated with hepatic resection (Hazard ratio [HR] = 0.28; 95% confidence interval [CI]: 0.12-0.65), residual stones (HR = 1.77; 95% CI: 1.05-2.98), and recurrent stones (HR = 4.02; 95% CI: 1.31-12.36), but not Sphincter of Oddi disruption. Though biliary stricture did not in general affect the cholangitis rate, a stricture located in the common hepatic or common bile duct was associated with a higher rate of cholangitis than a stricture in the intrahepatic duct alone. CONCLUSIONS: Cholangitis occurs frequently in hepatolithiasis patients with a common hepatic or common bile duct stricture, residual stones, recurrent stones, and in those that are treated by nonhepatic resection.     

Ceftriaxone versus Levofloxacin for antibiotic therapy in patients with acute cholangitis

INTRODUCTION: For the therapy of acute cholangitis complete biliary drainage and antibiotic therapy is needed. The aim of the current study was to compare intravenous therapy of acute cholangitis with Ceftriaxone or Levofloxacin in a prospective and randomized fashion. METHODS: Patients with biliary obstruction and clinical signs of infection received in addition to 1.5 g Metronidazole either 500 mg Levofloxacin/die or 2 g Ceftriaxone/die. Early on during ERCP, bile was aspirated via the cannulation catheter and cultured for bacteria under aerobic and anaerobic conditions. Minimal inhibitory concentrations of the respective antibiotics were determinate for each isolate. The clinical course was followed for at least 6 days with clinical and laboratory data. RESULTS: 60 patients with clinical signs of acute cholangitis were randomised. In 40 patients (66 %) biliary colonization with bacteria could be identified. In all bacterial species Levofloxacin showed significantly lower rates of in-vitro resistance as compared to Ceftriaxone. However, the percentage of patients with a clinical cure or significant improvement was the same in the two groups. CONCLUSIONS: The clinical effect of Levofloxacin and Ceftriaxone in patients with acute cholangitis showed no significant differences. Because of improved in-vitro efficiency, a calculated therapy with Levofloxacin might be advantageous.     

In vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens of acute cholangitis

AIM：To analyze the in vitro activity of moxifloxacin and piperacillin/sulbactam against pathogens isolated from patients with acute cholangitis. METHODS： In this prospective study a total of 65 patients with acute cholangitis due to biliary stone obstruction （n = 7）, benign biliary stricture （n = 16）, and malignant biliary stricture （n = 42） were investigated with regard to spectrum of bacterial infection and antibiotic resistance. Pathogens were isolated from bile cultures in all study patients. In 22 febrile patients, blood cultures were also obtained. In vitro activity of moxifloxacin and piperacillin/ sulbactam was determined by agar diffusion. RESULTS： Thirty-one out of 65 patients had positive bile and/or blood cultures. In 31 patients, 63 isolates with 17 different species were identified. The predominant strains were Enterococcus species （26/63）, Ecoli （13/63） and Klebsiella species （8/63）. A comparable in vitro activity of moxifloxacin and piperacillin/sulbactam was observed for E.coli and Klebsiella species. In contrast, Enterococcus species had higher resistances towards moxifloxacin. Overall bacteria showed antibiotic resistances in vitro of 34.9% for piperacillin/sulbactam and 36.5% for moxifioxacin.CONCLUSION： Enterococcus species, E.co/i and Klebsiella species were the most common bacteria isolated from bile and/or blood from patients with acute cholangitis. Overall, a mixed infection with several species was observed, and bacteria showed a comparable in vitro activity for piperacillin/sulbactam and moxifloxacin.     

Bile bacterial flora and its in vitro resistance pattern in patients with acute cholangitis resulting from choledocholithiasis

Abstract

Introduction. Cholangitis and biliary sepsis are severe infectious diseases, which are often observed in patients with choledocholithiasis. The antimicrobial therapy is effective if started as soon as the diagnosis is made. Therefore, the profile of bile pathogens and its susceptibility to a number of antibiotics were evaluated. Material and methods. Bile cultures and antibiograms from 92 patients hospitalized between January 2006 and December 2008 in a tertiary referral center for the treatment of biliary and pancreatic diseases (Central Teaching Hospital, Medical University of Silesia) were reviewed. Specimens were obtained from patients with acute cholangitis and confirmed choledocholithiasis during endoscopic (i.e. ERCP) and surgical (i.e. percutaneus transhepatic biliary drainage) procedures. The bile specimens were examined for pathogenic aerobic and anaerobic bacteria and fungi. Results. Sixty-five of 92 analyzed cultures were positive. A total of 69 pathogens were isolated: 47 (68.1%) Gram-negative bacteria, 18 (26.1%) Gram-positive bacteria, 2 (2.9%) anaerobes and 2 (2.9%) Candida. The predominant Gram-negative pathogens were Escherichia coli, Acinetobacter baumani complex, Klebsiella pneumoniae and Enterobacter cloacae. The most effective antibiotics against Gram-negative bacteria were imipenem, cefoperazone/sulbactam, piperacillin/tazobactam and cefepime (susceptibility 97.9%, 89.4%, 85.1% and 85.1%, respectively). The expenditure on antibiotics monotherapies and combined therapies was also analyzed. Conclusion. Our study shows that Gram-negative bacteria were the predominant bile pathogens found in patients with acute cholangitis. Piperacillin/tazobactam or ceftazidime may be the alternative to ciprofloxacin therapeutic option. The addition of ticarcillin/clavulanic acid to ciprofloxacin could also be considered. However, imipenem should remain a back-up antibiotic in the treatment of acute cholangitis.     

Bile duct bacterial isolates in primary sclerosing cholangitis and certain other forms of cholestasis--a study of bile cultures from ERCP

BACKGROUND/AIMS: The pathogenesis of the inflammatory lesion in primary sclerosing cholangitis is unknown. We have recently demonstrated a high positivity rate of bacterial cultures in bile and bile ducts of explanted livers from primary sclerosing cholangitis patients compared with patients with primary biliary cirrhosis. In particular, alpha-hemolytic Streptococci was a frequent finding, suggesting an etiopathogenic role of that particular bacteria in primary sclerosing cholangitis. We therefore wanted to study naive primary sclerosing cholangitis patients and compare them with primary sclerosing cholangitis patients that have previously undergone endoscopic retrograde cholangiopancreatography, in order to evaluate the potential role of these bacteria in the etiopathogenesis in primary sclerosing cholangitis. METHODOLOGY: Samples for bacterial cultures were obtained during a diagnostic endoscopic retrograde cholangiopancreatography. Participants: 12 naive primary sclerosing cholangitis patients, 10 patients with primary sclerosing cholangitis, previously investigated using endoscopic retrograde cholangiopancreatography, 47 patients with choledocholithiasis, 19 patients with cancer obstructing the common bile duct, and 29 patients with other forms of biliary disorders. RESULTS: Positive cultures were obtained from 3 of the naive primary sclerosing cholangitis patients and from 6 of the primary sclerosing cholangitis patients with previous endoscopic retrograde cholangiopancreatography (NS). The most frequent finding in all the primary sclerosing cholangitis patients was alpha-hemolytic Streptococci. Bacteria were cultured from the bile in 64% of the patients with choledocholithiasis, higher than the 25% in the naive primary sclerosing cholangitis patients (P < 0.03), and in 56% of patients with obstructing cancer (NS) but in only 24% of patients with other forms of biliary disorders, all of whom, except 4, had normal cholangiograms. In the 22 patients with primary sclerosing cholangitis, 75% of the positive bacterial cultures consisted of Gram-positive isolates and 25% were enteric bacteria, which differed statistically from the 74% enteric bacteria and 26% Gram-positive bacteria in the patients with common duct stone (P < 0.01). CONCLUSIONS: Alpha-hemolytic Streptococci do not seem to play a primary role in the etiopathogenesis of primary sclerosing cholangitis since most naive primary sclerosing cholangitis patients were found to have negative bacterial cultures. This does not exclude the possibility that they play a role in the progression of primary sclerosing cholangitis following infection in conjunction with the first endoscopic retrograde cholangiopancreatography.     

Bacteriology of the bile in cholecystopathies. Radiological association

A clinicobacteriological survey was undertaken in 55 patients undergoing biliary surgery, because of chronic and acute cholecystitis. Some radiological preoperative and operative aspects were analised in order to detect any relation of these aspects with biliary tract infection. The bile cultures were positive in 34,5% and 20,0% for aerobes an anaerobes microorganisms respectively. The microorganisms most frequently isolated were Escherichia coli, Pseudomonas aeruginosa, Klebsiella, Bacteroides sp and Clostridium sp, as aerobian and anaerobian. The statistical analysis showed significance between the presence of bacteria in the biliary tract and pathological operative cholangiography. It had not significance with the radiological preoperative aspects.     

经鼻胆管引流术后胆汁培养及药敏结果分析

目的对经鼻胆管引流术（ENBD）引流的胆汁培养阳性的细菌种类、比例及其药物敏感性进行分析,旨在指导胆道感染时正确选用抗生素。方法收集2013年1月至2013年4月在消化内科行经内镜逆行胰胆管造影（ERCP）后行ENBD的患者,对胆汁培养和药敏试验的结果作回顾性分析。结果208例患者中,180例为良性疾病,28例为恶性疾病,共112例（53.8％）胆汁培养阳性。最常见的细菌为大肠埃希菌（46.8％）、屎肠球菌（15.9％）、肺炎克雷伯杆菌（10.3％）和奇异变形杆菌（4.8oA）等。14例为多种微生物生长。无论患者疾病的良恶性、是否术前诊断急性胆管炎、是否术前已使用抗生素,其胆汁培养阳性率差异均无统计学意义（58.9％比71.4％,51.7％比67.9％,54.5％比52.9％,P〉0.05）。有无胆道手术史患者,其胆汁培养阳性率差异有统计学意义（87.09／6比49.7％,P〈0.01）。革兰阴性菌对泰能等敏感,革兰阳性菌对万古霉素等敏感。结论胆道手术史（包括ERCP及胆肠吻合）是胆道细菌生长的危险因素之一。胆道微生物的种类及药物敏感性,为临床经验性抗感染药物的选择提供了有力的依据。     

Treatment of complications of hepatic hydatid disease by ERCP

BACKGROUND: The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease. METHODS: Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients. OBSERVATIONS: In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic. CONCLUSION: Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.     

Bacteriologic analyses of bile and brown pigment stones in patients with acute cholangitis

BACKGROUND: Bacteria play an important role in the formation of brown pigment stones through adherence and biofilm formation. Scanning electron microscopy of cross sections of these stones reveals a laminated appearance and various bacteria in the different layers. Our postulation was that different bacteria might be involved at different stages of stone formation. METHODS: By using standard bacteriologic cultures, the composition, morphology, and antibiotic sensitivity patterns of bacteria isolated from paired stone were compared with bile samples from 70 patients with acute cholangitis. A further comparison was made between bacteria isolated from the periphery and center of 3 randomly selected brown pigment stones. RESULTS: Ninety-one percent of bile and 99% of stone samples yielded positive cultures, with a total of 151 and 149 bacteria isolated from bile and stones, respectively. In 22 patients (33%), the bacteria isolated from the paired bile and stone samples were totally different. The mean percentage similarity of bacteria isolated from bile and stones was 39% (range 0%-100%). Of the 59 pairs of similar bacteria isolated, the antibiotic sensitivity patterns were different in 24 (41%) cases. Of the 3 brown stones studied, either different bacterial species or the same bacteria but different strains with different antibiotic sensitivities were isolated from the center and periphery of the stones. CONCLUSIONS: Bacteria present in the different layers of brown pigment stones may represent the bacterial flora in bile at different times. Simple bile culture may not identify bacteria trapped inside the stone.     

Prostaglandin E receptors in bile ducts of hepatolithiasis patients and the pathobiological significance for cholangitis.

BACKGROUND & AIMS: In hepatolithiasis, chronic proliferative cholangitis may influence the progression of the disease. Prostaglandin (PG) E(2) experimentally causes morphologic changes to intrahepatic bile ducts, analogous to the changes found in cholangitis. This study was designed to gain an understanding of the involvement of PGE(2) and PGE receptor (EP) subtypes in the development of cholangitis. METHODS: The expression levels of secretory-type group IIA phospholipase A(2) (sPLA(2)-IIA) and cyclooxygenase (COX)-2 as well as EP subtypes were determined in the bile ducts with change of cholangitis. In in vitro experiments, growth promotion and mucin secretagogue properties of biliary epithelial cells in response to EP-selective agonists or antagonists were studied. RESULTS: The messenger RNA (mRNA) level of sPLA(2)-IIA and the protein and mRNA levels of COX-2 were significantly increased in the bile ducts of patients with hepatolithiasis compared with the levels of the bile ducts of control subjects. These changes were associated with a concomitant increase in PGE(2) and total mucin concentrations in the bile. The mRNAs of EP subtypes EP(2), EP(3), and EP(4) but not EP(1) were amplified in the bile ducts. Treatment with an EP(4)-selective agonist (ONO-AE1-329) caused a dose-dependent increase in DNA synthesis, colony number, and mucin secretion in the cells. Conversely, treatment with an EP(4)-selective antagonist (ONO-AE3-208) abolished the biological effects of PGE(2) on the cells. CONCLUSIONS: In hepatolithiasis, an enhanced synthesis of sPLA(2)-/COX-2-derived PGE(2) and its actions mediated via the EP(4) receptor in the bile ducts may be of pathobiological significance for chronic proliferative cholangitis.     

Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines

Unusual cases of acute cholecystitis and cholangitis include (1) pediatric biliary tract infections, (2) geriatric biliary tract infections, (3) acalculous cholecystitis, (4) acute and intrahepatic cholangitis accompanying hepatolithiasis (5) acute biliary tract infection accompanying malignant pancreatic-biliary tumor, (6) postoperative biliary tract infection, (7) acute biliary tract infection accompanying congenital biliary dilatation and pancreaticobiliary maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary tract infection is characterized by great differences in causes from those of adult acute biliary tract infection, and severe cases should be immediately referred to a specialist pediatric surgical unit. Because biliary tract infection in elderly patients, who often have serious systemic conditions and complications, is likely to progress to a serious form, early surgery or biliary drainage is necessary. Acalculous cholangitis, which often occurs in patients with serious concomitant conditions, such as those in intensive care units (ICUs) and those with disturbed cardiac, pulmonary, and nephric function, has a high mortality and poor prognosis. Cholangitis accompanying hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic disease in Southeast Asia. Biliary tract infections, which often occur after a biliary tract operation and treatment of the biliary tract, may have a fatal outcome, and should be carefully observed. The causes of acute cholangitis associated with pancreaticobiliary maljunction differ before and after operation. Direct cholangiography is most useful in the diagnosis of primary sclerosing cholangitis. If cholangiography visualizes a typical bile duct, differentiation from acute pyogenic cholangitis is easy. This article discusses the individual characteristics, diagnostic criteria, treatment guidelines, and prognosis of these unusual types of biliary tract infection.     

Modified method of hepatic portal choledochoplasty to treat benign strictures of hilar biliary ducts

Background and Aim:  Roux-en-Y hepaticojejunostomy (RYHJ) is usually used to treat benign strictures of hilar bile ducts. However, RYHJ might also induce ascending cholangitis and recurrent hepatolithiasis. The present study aims to introduce a modified hepatic portal choledochoplasty with a pedicled graft of gallbladder (HPC) to treat this disease.
Methods:  One hundred and forty-nine patients, who had undergone HPC or RYHJ from January 1997 to January 2006 in our institutions, were included in this study, and the clinical data were retrospectively collected and analyzed.
Results:  The incidences of perioperative bile leakage and inflammatory ileus in patients treated with HPC were slightly lower than RYHJ without significant difference (1.89% vs 2.08% and 3.77% vs 5.21%, both P  > 0.05). However, in a long-term follow up, patients treated with HPC had significantly lower incidences of cholangitis and recurrent hepatolithiasis (5.66% and 3.77%, respectively) than those treated with RYHJ (cholangitis, 21.88%; hepatolithiasis, 16.67%; both P  < 0.05).
Conclusion:  Compared to RYHJ, HPC is a safer and more efficient method to treat benign strictures of hilar biliary ducts. It preserves the sphincter of Oddi and normal biliary duct pressure, thus avoiding bile reflux into the bile duct.     

Microbiology of choledochal bile in patients with choledocholithiasis admitted to a tertiary hospital

AIM: The present study was designed to investigate the microbiology of choledochal bile of patients with cholangitis and choledocholithiasis. METHODS: We identified and determined the antimicrobial susceptibility of bacteria isolated in the bile of patients with cholangitis and choledocholithiasis diagnosed by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Nineteen (82.6%) of 23 patients with choledocholithiasis had positive bile cultures. A single agent was detected in 11 patients (57.9%), while a mixed growth, with pathogens ranging from two to three species, were seen in eight patients (42.1%). Patients with clinical manifestations of cholangitis had significantly higher counts of colonies per mL of bile (> 105 cfu/mL).The predominant Gram-negative aerobic bacteria isolated were Escherichia coli (9, 31.0%), Klebsiella pneumoniae (5, 17.2%), Enterobacter cloacae (2, 6.9%), Pantoea agglomerans (1, 3.4%), and Pseudomonas aeruginosa (1, 3.4%). The predominant Gram-positive bacteria were Enterococcus faecalis (5, 17.2%) and Streptococcus sp. (5, 17.2%). Bacteroides fragilis was isolated in one patient with mixed growth. All Gram-positive bacteria isolated in bile were sensitive to ampicillin, and all Gram-negative bacteria isolated were sensitive to gentamicin with a minimum inhibitory concentration (CIM90) ranging from 0.5 to 1.0- micro g/mL. Gram-negative bacteria were also sensitive to imipenem, fluorquinolones, second and third generation cephalosporins. Although all five isolates of E. faecalis were sensitive to ampicillin, two of five (40%) E. faecalis isolates demonstrated high levels of resistance to gentamicin. CONCLUSION: E. coli, K. pneumoniae, E. faecalis and Streptoccocus sp. were the most common bacteria isolated in the bile of patients with cholangitis and choledocholithiasis, which were sensitive to a simple therapeutic regimen, such as the combination of ampicilin and gentamicin.     

Intrahepatic cholangiocarcinoma in Taiwan

We report our experience of the surgical treatment of intrahepatic cholangiocarcinoma (ICC) in Taiwanese patients. A tota1 of 162 patients with histologically proven ICC were treated of whom 106 (65.4%) had associated hepatolithiasis. Patients with hepatolithiasis were in earlier stages than those without hepatolithiasis. Two-thirds of the patients with hepatolithiasis presented with acute cholangitis, and two-thirds of those without hepatolithiasis presented with hepatomegaly. The rate of hepatic resection was 29.6% (48 of 162), and these rates were 31.1% and 26.8% for the patients with and without hepatolithiasis, respectively. Ninety-three percent of the patients with hepatolithiasis underwent common bile duct exploration, compared with 18% of those without hepatolithiasis. The surgical mortality rates were 3.7% (6/162), for all patients, and 3.8% and 3.6% for patients with and without hepatolithiasis, respectively. The morbidity rate was much higher in the patients with hepatolithiasis (37.7% vs 16.1%). The 1-, 3-, and 5-year survival rates were 35.5%, 20.5%, and 16.5% in the patients with hepatolithiasis and 27.2%, 8.8%, and 7.8% in those without hepatolithiasis. Concomitant hepatolithiasis prevented precise diagnosis preoperatively and precipitated biliary sepsis, which affected resectability and increased postoperative morbidity. Hepatolithiasis per se did not influence long-term survival.     

Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients

AIM: To identify the frequency of bacterial growth, the most commonly grown bacteria and their antibiotic susceptibility, and risk factors for bacterial colonization in bile collected from patients with different biliary diseases.METHODS: This prospective study was conducted between April 2010 and August 2011. Patients with various biliary disorders were included. Bile was aspirated by placing a single-use, 5F, standard sphincterotome catheter into the bile duct before the injection of contrast agent during endoscopic retrograde cholangiopancreaticography (ERCP). Bile specimens were transported to the microbiology laboratory in blood culture bottles within an anaerobic transport system. Bacteria were cultured and identified according to the standard protocol used in our clinical microbiology laboratory. The susceptibilities of the organisms recovered were identified using antimicrobial disks, chosen according to the initial gram stain of the positive cultures.RESULTS: Ninety-one patients (27% male, mean age 53.7 ± 17.5 years, range: 17-86 years) were included in the study. The main indication for ERCP was benign biliary disease in 79 patients and malignant disease in 12 patients. The bile culture was positive for bacterial growth in 46 out of 91 (50.5%) patients. The most frequently encountered organisms were Gram-negative bacteria including Escherichia coli (28.2%), Pseudomonas (17.3%) and Stenotrophomonas maltophilia (15.2%). There were no significant differences between patients with malignant and benign disease (58% vs 49%, P = 0.474), patients with acute cholangitis and without acute cholangitis (52.9% vs 50%, P = 0.827), patients who were empirically administered antibiotics before intervention and not administered (51.4% vs 60.7%, P = 0.384), with regard to the bacteriobilia. We observed a large covering spectrum or low resistance to meropenem, amikacin and imipenem.CONCLUSION: We did not find a significant risk factor for bacteriobilia in patients with biliary obstruction. A bile sample for microbiological analysis may become a valuable diagnostic tool as it leads to more accurate selection of antibiotics for the treatment of cholangitis.