Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis

BACKGROUND: Cholangitis is a frequent complication of biliary stents. Empiric antibiotic selection is primarily based on bile cultures obtained from patients undergoing surgery and few data are available with respect to ERCP and biliary stents. This study analyzed the microbiology of bile and the antibiotic sensitivities of the organisms identified in patients presenting with clinical cholangitis or cholestasis. METHODS: All bile cultures collected during ERCP from January 1994 to January 2000 were identified by using an ERCP database. RESULTS: One hundred eighty cultures from 160 patients (mean age 55 years, range 6-94 years) were identified. Sixty-nine specimens were collected at ERCPs performed in patients with no biliary stent in place (group 1). One hundred eleven specimens were obtained from patients with a biliary stent in situ (group 2). The primary diagnoses for patients in groups 1 and 2 were as follows, respectively: malignant bile duct obstruction (25 and 85), choledocholithiasis (16 and 2), benign biliary strictures (6 and 18), acquired immunodeficiency syndrome (8 and 0), and miscellaneous (14 and 6). There were 38 positive bile cultures in group 1 (55%) and 109 positive cultures in group 2 (98%; p < 0.05). A higher frequency of polymicrobial infections (90%) was found in group 2 patients (vs. group 1, 45%; p < 0.001). Escherichia coli was the most common organism found in group 1 (17%); Enterococcus the most common in group 2 (31%). Among patients with positive bile cultures, bacteremia was more frequent in group 2 patients (46% vs. 21%; p < 0.05). Ciprofloxacin and cefiriaxone were the most effective antibiotics against identified gram-negative bacilli, and vancomycin against Enterococci. CONCLUSION: In patients with cholangitis associated with biliary obstruction, the antibiotic selected initially should be active against gram-negative bacilli. Use of quinolones is recommended because these agents effectively penetrate an obstructed biliary tree and can be administered orally. Enterococci and polymicrobial infections are found more commonly in patients with a biliary stent than those without a stent. Pending definitive biliary decompression, patients with sepsis and those who do not quickly respond to treatment with a quinolone may benefit from the addition of antibiotic coverage against gram-positive organisms, targeted against Enterococci.     

Significance of telemedicine for video image transmission of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography procedures

Background

With the rapid and marked progress in gastrointestinal endoscopy, the education of doctors in many new diagnostic and therapeutic procedures is of increasing importance. Telecommunications (telemedicine) is very useful and cost-effective for doctors?? continuing exposure to advanced skills, including those needed for hepato-pancreato-biliary diseases. Nevertheless, telemedicine in endoscopy has not yet gained much popularity. We have successfully established a new system which solves the problems of conventional ones, namely poor streaming images and the need for special expensive teleconferencing equipment.

Methods

The digital video transport system, free software that transforms digital video signals directly into Internet Protocol without any analog conversion, was installed on a personal computer using a network with as much as 30?Mbps per channel, thereby providing more than 200 times greater information volume than the conventional system. Kyushu University Hospital in Japan was linked internationally to worldwide academic networks, using security software to protect patients?? privacy.

Results

Of the 188 telecommunications link-ups involving 108 institutions in 23 countries performed between February 2003 and August 2009, 55 events were endoscopy-related, 19 were live demonstrations, and 36 were gastrointestinal teleconferences with interactive discussions. The frame rate of the transmitted pictures was 30/s, thus preserving smooth high-quality streaming.

Conclusions

This paper documents the first time that an advanced tele-endoscopy system has been established over such a wide area using academic high-volume networks, funded by the various governments, and which is now available all over the world. The benefits of a network dedicated to research and education have barely been recognized in the medical community. We believe our cutting-edge system will be a milestone in endoscopy and will improve the quality of gastrointestinal education, especially with respect to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures.     

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

Background

Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live.

Methods

The expert working party, predominantly from the Asia–Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted.

Results

AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (<30 min of hospitalization) and endoscopic variceal ligation (door to scope time <6 h) is accepted as first-line therapy. Rebleeding (48 h of T ₀) is further sub-classified as very early rebleeding (48 to 120 h from T ₀), early rebleeding (6 to 42 days from T ₀) and late rebleeding (after 42 days from T ₀) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of non-response to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients.

Conclusion

Management of acute variceal bleeding in Asia–Pacific region needs special attention for uniformity of treatment and future clinical trials.