Cholangitis score: a scoring system to predict severe cholangitis in gallstone pancreatitis

Abstract. Background/Purposes: Emergency biliary decompression and stone extraction are mandatory for patients with gallstone pancreatitis who have ampullary stone impaction or persistent stones and pus in the bile duct (severe cholangitis). The aim of this study was to devise a simple scoring system for the prediction of complicating severe cholangitis in gallstone pancreatitis. Methods: Clinical signs, laboratory data, and ultrasonography (US) findings at the time of admission, and the bile duct pathology at the time of bile duct exploration, were reviewed in 66 patients with gallstone pancreatitis. Variables which discriminated 26 patients with bile duct stones from 40 without were defined as predictive factors of bile duct stones. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff values of numerical variables. One point was allocated to each predictive factor, and the total score was defined as the cholangitis score (CS). Bile duct pathology identified at the time of bile duct exploration was graded into three categories: mild, moderate, and severe cholangitis. A threshold value of the CS, claimed to be predictive of severe cholangitis, was determined by using the ROC curve. Results: The scoring system consisted of four predictive factors: (1) pyrexia (temperature ≧38 °C), (2) elevated serum bilirubin (≧2.2 mg/dl), (3) dilated bile duct (≧11 mm maximum diameter on US), and (4) bile duct stones detected on US. The scoring system predicted severe cholangitis with 92% sensitivity and 98% specificity in patients with scores of three or four points. Conclusions: Patients with gallstone pancreatitis who meet three or four of the above predictive factors at the time of admission are likely to have severe cholangitis, and should be rapidly treated by biliary decompression and stone extraction. Received: July 13, 2001 / Accepted: November 16, 2001     

Gallstone ileus diagnosed preoperatively using ultrasonic tomography

We treated a man with gallstone ileus and a correct diagnosis was made preoperatively. In this report, emphasis was placed on the usefulness of application of ultrasonic tomography for diagnosing an acute abdomen.     

海南地区135例胆石病的特点和临床流行病学调查

目的 探讨海南地区胆石病的临床流行病学特点，及其影响因素。方法 本文对海南地区135例胆石病患者进行回顾性流行病学因素调查，对术中取得的胆石进行化学成分测定。结果 胆管结石占51.9%，胆固醇类结石占65.9%。城镇居民、高脂饮食及肥胖者的胆囊结石发病率高，而农村居民、低脂饮食者的胆管结石发病率高。胆管结石患者的胆汁细菌培养阳性率（65.7%)高于胆囊结石患者的胆汁细菌培养阳性率（18.5%)。结论 海南地区胆石的分布部位胆囊结石与胆管结石比例接近；类型以胆固醇类结石为主。职业、生活条件、饮食习惯等因素与胆囊结石和胆管结石的发病率有关。高脂饮食及肥胖是造成胆囊结石的主要因素，而低营养、低脂饮食与胆管结石的形成有关。反复胆道细菌感染在胆管结石形成中可能起重要作用。     

Hypothermia protects against gut ischemia/reperfusion-induced impaired intestinal transit by inducing heme oxygenase-1

PURPOSE: Gut ischemia/reperfusion (I/R) elicits an inflammatory response that impairs intestinal transit. We have previously shown that regional intraischemic hypothermia (IH) protects against moderate gut I/R-induced mucosal injury, is associated with decreased NF-kappaB activity and inducible nitric oxide synthase induction and preserves heme oxygenase-1 (HO-1) expression. HO-1 provides cytoprotection in various models of oxidant stress. We, therefore, tested the hypothesis that IH protects against gut I/R-induced impaired intestinal transit via HO-1 induction. MATERIALS AND METHODS: At laparotomy (lap), Sprague-Dawley rats had duodenal catheters placed followed by sham or gut I/R (superior mesenteric artery occlusion for 75 min) with or without regional IH (15 degrees C). Each animal was placed on a heating blanket maintaining systemic normothermia (37 degrees C). At 12 or 24 h of reperfusion, small intestinal transit was determined by quantitating the distribution of a tracer (FITC dextran) in the intestine 30 min after instillation (expressed as geometric center of distribution). Ileal samples were obtained for histology and HO-1 expression, assessed by Western immunoblot at 12 and 24 h of reperfusion. In separate experiments, rats were pretreated with an HO-1 inhibitor Sn protoporphyrin IX (25 mumol/kg, ip), 1 h before superior mesenteric artery occlusion and transit measured as above. RESULTS: Rats treated with I/R had increased histological injury and impaired intestinal transit at both 12 and 24 h compared with sham. Rats treated with I/R+IH exhibited histological injury and transit comparable with sham controls. I/R induced HO-1 expression at 12 and 24 h of reperfusion and IH augmented this I/R-induced HO-1 expression. Sn protoporphyrin IX abrogated IH protection against histological injury and impaired transit. CONCLUSION: We conclude that intraischemic regional hypothermia protects against histological injury and impaired intestinal transit caused by severe gut I/R injury. Hypothermic protection under these conditions is in part due to HO-1 expression.     

Early enteral feeding after closure of colostomy in pediatric patients

Background/Purpose

The aim of this study was to determine the benefits and adverse effects of protocolized early postoperative enteral feeding in pediatric patients undergoing a closure of colostomy.

Methods

Pediatric patients, completely treated for anorectal malformation, who underwent a closure of colostomy during September 2000 and May 2002 received early postoperative feeding according to the authors’ protocol (EF group). Retrospective data of consecutive patients operated on from March 1998 to August 2000 who received traditional feeding practice were used as a control (TF group). The protocol began with a small volume of formula or breast feeding within the first postoperative day. Volume allowance was advanced every 4 hours up to the daily maintenance volume. Full feeding was defined as when the patient was able to tolerate at least 80% of daily maintenance volume. TF group received nothing by mouth until documentation of bowel function. The groups were compared with regard to postoperative stay, postoperative hour of full feeding, first bowel movement, and adverse effects. Statistical analyses were performed with χ² test, Student’s t test, and Mann-Whitney U test.

Results

There were 34 and 30 patients in EF and TF groups, respectively. Median age of the patients was 13 months, and median weight was 8.39 kg. Except for the associated anomalies, which were found more in the EF group, there were no differences in the demographic characteristics of the 2 groups. On average, feeding was initiated at 19.7 (16 to 24) hours in the EF group and 51.7 (18 to 92) hours in the TF group (P < .01). Median full feeding hours were 45.5 and 70.5 hours in the EF and TF group, respectively (P < .01). First bowel movement in the EF group was recorded at the average of 4.14 postoperative nurse shifts, compared with 5.96 shifts in the TF group (P < .01). Postoperative stay was significantly reduced from the average of 6.1 days to 4.5 days (P < .01). The overall hospital expenses were not significantly different between the 2 groups. ($203.95 US in TF group and $198.50 US in EF group; P = .75) There was 1 vomiting case in the EF group that was temporary and resolved spontaneously. Septic complications were noted in 8 patients in the EF group and 6 patients in the TF group (P = .27). The majority were uncomplicated urinary tract infections.

Conclusions

Early feeding after a closure of colostomy in pediatric patients stimulated early bowel movement and reduced hospital stay with no increased adverse effects.     

Surveillance for cystic fibrosis-associated hepatobiliary disease: early ultrasound changes and predisposing factors

OBJECTIVE: To investigate routine ultrasonography (US) as an early marker and to identify risk factors for the development of cirrhosis and portal hypertension (PHT) in cystic fibrosis (CF). STUDY DESIGN: A cohort of 106 children with CF aged 5.9+/-2.3 years were followed for 10.4+/-0.2 years in a CF clinic. RESULTS: At enrollment, the US was normal, but biochemical and/or clinical disease was present in 10%. By the end of the study, 19 had developed US changes, eight with evidence of PHT. At the time of the initial US change, only 36.4% of those had, at the end of the study, either a heterogeneous or a nodular parenchyma, and only 50% of those with PHT had biochemical and/or clinical disease. Of the 30 patients treated with ursodeoxycholic acid for biochemical and/or clinical disease with (n=15) and without (n=15) associated US changes, PHT developed in six of the former and two of the latter. Univariate analysis and logistic regression showed that children with more severe disease in terms of forced expiratory volume in one second were at somewhat greater risk (P<.06) of PHT developing. CONCLUSION: US was an early marker of liver disease and more severe CF disease, a predictor of progressive liver disease. A controlled trial should be done to assess isolated US-detected disease as an indication for UDCA.     

Does mechanical massage of the abdominal wall after colectomy reduce postoperative pain and shorten the duration of ileus? Results of a randomized study

The aim of this study was to determine the effectiveness of mechanical abdominal massage on postoperative pain and ileus after colectomy. We hypothesized that parietal abdominal stimulation could counteract induced pain and postoperative ileus, through common spinal-sensitive pathways, with nociceptive visceral messages. After preoperative randomization, 25 patients (age 52 ± 5 years) underwent active mechanical massage by intermittent negative pressure on the abdominal wall resulting in aspiration (Cellu M50 device, LPG, Valence, France), and 25 patients (age 60 ± 6 years) did not receive active mechanical massage (placebo group). Massage sessions began the first day after colectomy and were performed daily until the seventh postoperative day. In the active-massage group, amplitude and frequency were used, which have been shown to be effective in reducing muscular pain, whereas in the placebo group, ineffective parameters were used. Visual analogue scale (VAS) pain scores, doses of analgesics (propacetamol), and delay between surgery and the time to first passage of flatus were assessed. Types and dosages of the anesthetic drugs and the duration of the surgical procedure did not differ between groups. From the second and third postoperative days, respectively, VAS pain scores (P < 0.001) and doses of analgesics (P < 0.05) were significantly lower in patients receiving active massage compared to the placebo group. Time to first passage of flatus was also significantly shorter in the active-massage group (1.8 ± 0.3 days vs. 3.6 ± 0.4 days, P < 0.01). No adverse effects were observed. These results suggest that mechanical massage of the abdominal wall may decrease postoperative pain and ileus after colectomy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001 (oral presentation).     

Cystic fibrosis in Ontario

The incidence of cystic fibrosis in Ontario, Canada has been determined from clinical data, from the cystic fibrosis database of the Hospital for Sick Children, Toronto, and from population statistics in the Province of Ontario. The survey included 420 confirmed cases of cystic fibrosis born during the period 1966–1980. The mean incidence during this period was one in 2,927. In the last 5-year period, a decline was noted in incidence that may have reflected in part the effectiveness of early diagnosis and genetic counseling in affected families. During the period of the survey, over 60% of cases were diagnosed within the first year of life, 74% by age 2 years, and 90% by age 5 years. Clinical diagnosis in the first year of life was more common in males (65%) than in females (54%), a consistent finding during the period of the survey. The incidence of meconium ileus was 15.7% of ascertained cases of cystic fibrosis, with similar incidences in males (16.4%) and females (14.4%). Although survival has not been the subject of this survey, mortality in the neonatal period was significantly higher in males than in females with cystic fibrosis.     

Incidence of cholelithiasis among patients with cirrhosis and portal hypertension

One hundred and two patients with cirrhosis and portal hypertension were evaluated sonographically to determine the presence or absence of cholelithiasis. The gallbladder was visualized in 80 of 102 patients. Cholelithiasis was present in 43 of 80 cases (54%). All 22 patients in whom the gallbladder was not seen sonographically had had a previous cholecystectomy. Five of them were operated on prior to development of cirrhosis with portal hypertension, but 14 of the remaining 17 (82%) had evidence of cholelithiasis at pathology. Hence, there was an overall incidence of cholelithiasis of 59% among our 97 patients. This study as well as previous autopsy data indicate an increased incidence of cholelithiasis in patients with cirrhosis, irrespective of etiology or sex. The incidence of cholelithiasis in this study, however, was approximately twice that previously reported in cirrhotics at autopsy. Furthermore, patients with portosystemic shunts showed a significantly higher incidence of cholelithiasis compared to patients who were not shunted (68% vs 49%,p=0.028). We believe the severity and duration of cirrhosis in our patient population, all with documented portal hypertension, may be the cause of this increased incidence.     

GALL BLADDER PERFORATIONS

Twenty-seven patients with gall bladder perforation were reviewed. Free perforation into the peritoneal cavity producing bile peritonitis occurred in 45% of patients. Bilio-enteric fistulae were encountered in 48% of our patients. Five patients had gall stone ileus. A mortality of 11% reflects the serious nature of the condition. Selection of the optimum surgical procedure is based on the evaluation of the individual patient which should include an estimate of the general condition of the patient as well as the evaluation of anatomic situation at operation. Our experience suggests that cholecystostomy may be life-saving in these patients. Surgery in patients with gall stone ileus should be directed towards relief of obstruction only.