Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Incidence, dianosis and management of Mirizzi syndrom in Kuwait

Mirizzi syndrome is an obstructive jaundice associated with pressure on the common hepatic duct from gallstones in Hartmann's pouch or the cystic duct. The stones sometimes erode through the main duct, leaving a fistula. We reviewed cases encountered between January 2001 and November 2002. Retrospective review of seventeen patients with diagnosis of Mirizzi syndrome managed in the surgical wards of Farwaniya Hospital. Patients were fully investigated including liver function tests, abdominal ultrasonography, ERCPand/or intra-operative cholangiography. During the study period 625 cholecystectomies were performed. Out of these, 17 were found to have Mirizzi syndrome which accounts for an incidence of 2.72%. In 11 patients, jaundice resulted from gallstone pressure [type I] and in the remaining six patients, the stones had eroded into the common hepatic duct producing a fistula [type II]. The diagnosis can usually be made preoperatively, especially if a large single stone is seen in conjunction with a dilated common hepatic duct and normal caliber common bile duct. We favor partial cholecystectomy, adding choledochoplasty using the gallbladder remnant, to close the fistula in type II cases