Cáncer de vesícula biliar ¿la contaminación por bilis afecta el pronóstico? / Gallbladder Cancer: does bile contamination affect the prognosis?

Resumen Introducción: En algunas áreas el cáncer de la vesícula biliar se detecta en hasta el 3,5% de los pacientes intervenidos por colelitiasis. Con el objetivo de evaluar el rol de la ruptura de la vesícula y la consiguiente contaminación por bilis, se evaluó una serie de pacientes portadores de cáncer de vesícula diagnosticado posterior a la colecistectomía. Materiales y Método: El estudio se efectuó en 109 pacientes en quienes se diagnosticó un cáncer de vesícula posterior a la colecistectomía. El grupo a estudiar se dividió de acuerdo a la ocurrencia o no de contaminación por bilis al momento de la colecistectomía, como también de acuerdo a la magnitud de ésta. Resultados: De los pacientes estudiados, en 32 se documentó la ocurrencia de contaminación por bilis al momento de la colecistectomía. De estos, en 13 la contaminación fue considerada mayor. El tiempo promedio de seguimiento fue de 33 meses, 35 pacientes (32,1%) fallecieron durante el seguimiento. La sobrevida media de la totalidad de la serie que tuvo contaminación por bilis no se diferenció de los pacientes sin contaminación. Sin embargo, el grupo que tuvo una contaminación catalogada como mayor, presentó una sobrevida estadísticamente inferior al resto de los pacientes. Finalmente, se realizó un análisis mediante el modelo de regresión de COX que incluyó edad, género, nivel de invasión y tipo de contaminación, resultando la existencia de contaminación mayor por bilis un factor independientemente asociado al pronóstico. Conclusión: La presencia de ruptura vesicular y contaminación mayor por bilis debiera considerarse un factor pronóstico.

Background: Incidental gallbladder cancer is observed in up to 3.5% of patients undergoing laparoscopic cholecystectomy. To study the role of wall perforation on the prognosis, we evaluated a series of patients in whom perforation occurred during the cholecystectomy. Materials and Method: 109 patients who underwent a laparoscopic cholecystectomy in whom final diagnosis was gallbladder cancer were the focus of the study. We divided the patients according the occurrence of spillage. Furthermore, patients with spillage were divided into two categories according the spillage magnitude. Results: Of the patients, spillage was documented in 32 (29.3%). In 13 patients spillage was considered major. The median follow-up of patients was 36 months, while 35 (32.1%) patients died during the follow-up. Five-year survival of all patients with spillage was not statistically different from the group without spillage. However, the group with major spillage had a statistically worse survival than the rest. A Cox regression analysis including age, gender, level of invasion and spillage category showed that major spillage was independently associated with a worse prognosis.

Prevalence of bacteriobilia in patients undergoing elective colecystectomy / Prevalência de bacteriobilia em pacientes submetidos à colecistectomia eletiva

ABSTRACT Background: Cholelithiasis is one of the diseases with greater surgical indication. Currently, laparoscopic cholecystectomy is the gold standard in the treatment of cholelithiasis. Aim: To analyze the culture of bile from patients with cholelithiasis, mainly in the occurrence of brown and mixed stones. Methods: Was carried out a prospective study with 246 cases with biliary lithiasis who underwent elective laparoscopic cholecystectomy. Bile culture was performed in all. During anesthetic induction the patients received a single dose of intravenous cefazolin 1 g. At the end of the surgery, the gallbladder was punctured, its contents extracted and immediately placed in a sterile 20 ml propylene flask and promptly sent to bacterioscopy with Maconkey and blood agars. Incubation at 37° C for 24 h was carried out. A protocol was elaborated to include the main factors potentially related to cholelithiasis and the possible presence of associated bacterial infection. Results: Of the 246 patients, 201 had negative bile culture and 45 positive. Of the 45 patients with bacteriobilia, 34 had growth of a single type of bacterium in bile culture and 11 more than one. Conclusions: It was observed a relationship between bacteriobilia and age, suggesting that age is a risk factor for bacteriobilia. The use of antibiotic prophylaxis in the elderly is therefore recommended.

RESUMO Racional: A colecistolitíase é uma das doenças que têm maior indicação cirúrgica. Atualmente a colecistectomia laparoscópica é o padrão-ouro no seu tratamento. Objetivo: Analisar a cultura da bile de pacientes portadores de colecistolitíase, principalmente na ocorrência de cálculos com pigmentos marrons e mistos. Métodos: Foi realizado estudo prospectivo de 246 casos de pacientes portadores de litíase biliar, submetidos à colecistectomia laparoscópica eletiva, sendo realizada cultura da bile. Durante a indução anestésica os pacientes receberam dose única de cefazolina 1 g, intravenosa. No final da operação foi puncionada a vesícula biliar, extraído seu conteúdo e imediata colocação em frasco estéril de propileno de 20 ml e prontamente encaminhado para bacterioscopia com semeadura do material coletado em ágar sangue e de Maconkey com posterior incubação em estufa de cultura a 37° C durante 24 h. Foi elaborado um protocolo capaz de englobar os principais fatores potencialmente relacionados à colecistolitíase e a possível presença de infecção bacteriana associada. Resultados: Dos 246 participantes, 201 tiveram cultura de bile negativa e 45 positiva. Dos 45 pacientes com bacteriobilia, 34 tiveram crescimento de um único tipo de bactéria e 11 mais de uma. Conclusões: Foi observada relação entre bacteriobilia e a idade, sugerindo que a idade é fator de risco para bacteriobilia. Recomenda-se assim o emprego de antibioticoprofilaxia nos idosos.

Microbiological analysis of bile in patients with benign and malignant biliopancreatic diseases and its consequences / Análise microbiológica da bile em pacientes com doenças biliopancreáticas benignas e malignas e suas consequências

ABSTRACT Background Bactibilia has several consequences to human health. Objetive Assessing the bile microbiology of patients with biliopancreatic diseases in order to identify bacteria and their possible infectious complications. Methods Retrospective study of 30 bile culture samples from patients with benign and malignant biliopancreatic diseases. The samples were assessed to set the bile microbiological flora and to search for its possible link with comorbidity, carcinogenesis and postoperative infectious complications. Results Thirty bile samples from patients at mean age ≈57.7 years, mostly female (n=18), were assessed. Bactibilia was found in 12 cases, mostly in patients with benign diseases (n=8), older than 50 years (n=23) and female (n=10). Adenocarcinoma of the duodenal papilla (n=9) and cholelithiasis (n=8) were the most common diseases. Escherichia coli (n=5) and Klebsiella sp (n=3) were predominantly found in patients with benign diseases; and Klebsiella sp (n=2) and Streptococcus sp (n=2) were prevalent in cancer patients. There were postoperative infectious complications in seven cases, five of them in bactibilia-associated patients (P=0.084). Conclusion Bactibilia was found in 12 samples and Escherichia coli and Klebsiella sp were most often identified in patients with benign diseases, as well as Streptococcus sp and Klebsiella sp in cancer patients. There was a trend of higher postoperative infectious complication incidence in patients with bactibilia.

RESUMO Contexto Bacteriobilia pode produzir várias consequências para a saúde humana. Objetivo Avaliar a microbiologia da bile de pacientes com doenças biliopancreáticas para identificar bactérias e possíveis consequências. Métodos Estudo retrospectivo microbiológico. Trinta amostras de bile de pacientes com doenças biliopancreáticas benignas e malignas foram avaliadas para determinar a flora microbiológica da bile e procurar alguma possível relação dessa com comorbidades, carcinogênese e complicações infecciosas pós-operatórias. Resultados As amostras de bile foram avaliadas em pacientes, com idade média ≈57,7 anos, a maioria mulheres (n=18). Evidenciou-se bacteriobilia em 12 casos, a maioria em pacientes com doenças benignas (n=8); pacientes com mais de 50 anos (n=23) e mulheres (n=10). As doenças mais comuns foram o adenocarcinoma de papila duodenal (n=9) e a colelitíase (n=8). Escherichia coli (n=5) e Klebsiella sp (n=5) foram as bactérias mais identificadas em pacientes com doenças benignas; sendo a Klebsiella sp (n=2) e o Streptococcus sp (n=2) as que predominaram nos pacientes com cânceres. As complicações pós-operatórias exclusivamente infecciosas ocorreram em sete casos, sendo em cinco desses associados à bacteriobilia (P=0,084). Conclusão Bacteriobilia foi evidenciada em 12 amostras, sendo as bactérias mais identificadas Escherichia coli e Klebsiella sp em pacientes com doenças benignas; e Streptococcus sp e Klebsiella sp nos pacientes com câncer. Existiu uma tendência a maior incidência de complicações infecciosas pós-operatórias em pacientes com bacteriobilia.

Frequency of common bacteria and their antibiotic sensitivity in patients with symptomatic cholelithiasis

To determine the frequency of common bacteria and their antibiotic sensitivity in patients with symptomatic cholelithiasis This cross sectional descriptive study was conducted at Department of Surgery, Lady reading hospital, Peshawar for 6 months i.e., from December 2012 to May 2013. The total number of patients were 126. They presented with symptomatic cholelithiasis. Bile was aspirated preoperatively before cholecystectomy from gall bladder and was sent for culture and sensitivity test. The data was analyzed using Statistical Package for Social Sciences[SPSS] version 10.0. On culture and sensitivity test, 74 [58.73%] have positive growth while 52 [41.27%] have no growth. The most common bacteria was E. Coli isolated in 28 [22.22%] patients followed by Klebseilla in 22 [17.46%], Salmonellain 16 [12.70%] and Shigella in 8 [6.35%] patients. On culture and sensitivity test, all the 4 isolated bacteria showed sensitivity to Cefuroxime, Ceftriaxone and Ciprofloxacin in more than 50 % cases, while all the four bacteria showed resistance to amoxicillin in more than 50 % cases. The most common bacteria of symptomatic cholelithiasis are E. coli and Klebseilla followed by Salmonella and Shigella. These bacteria showed maximum sensitive to cefuroxime and ceftriaxone

Bactibilia e infección del sitio quirúrgico posterior a colecistectomía abierta / Bactibilia and surgical site infection after open cholecystectomy

Introducción: La bactibilia es la presencia de bacterias en bilis vesicular y está relacionada con la aparición de complicaciones sépticas y con el desarrollo de infección en herida quirúrgica de la colecistectomía. En este estudio investigamos si la bactibilia se correlaciona con infección de herida posterior a colecistectomía abierta. Material y métodos: Estudio observacional, descriptivo, de pacientes sometidos, entre enero y diciembre de 2006, a colecistectomía abierta en forma electiva por colecistitis crónica litiásica, a quienes se les realizó cultivo de bilis en el transoperatorio. Se identificaron dos grupos: con cultivo biliar negativo (grupo 1) y con cultivo biliar positivo (grupo 2). Las variables estudiadas fueron edad, sexo, resultados del cultivo, absceso, celulitis, seroma y hematoma. El análisis estadístico incluyó c2 de Pearson o prueba exacta de Fisher y t de Student. Resultados: Se estudiaron 80 pacientes (n = 40 por grupo), 24 hombres (30%) y 56 mujeres (70%), en quienes se practicó colecistectomía abierta y que contaban con cultivo biliar para el análisis. La morbilidad general fue de 42.5%. La tasa de infección del sitio quirúrgico fue de 11.25%. En el grupo 1, dos pacientes presentaron abscesos y dos celulitis; en el grupo 2, cuatro abscesos y uno celulitis. No hubo diferencia significativa al comparar la infección del sitio quirúrgico entre ambos grupos. Conclusiones: La presencia de bacterias en los cultivos de bilis vesicular no se correlacionó con el desarrollo de infección en herida quirúrgica posterior a colecistectomía.

BACKGROUND: Bactibilia is the presence of bacteria in gall bladder bile and may play a role in the appearance of septic complications. It has been related to increased rates of surgical site infection after cholecystectomy. In this study we investigated whether bactibilia correlates with the presence of surgical site infection after cholecystectomy. METHODS: In this observational and descriptive study we investigated those patients operated by open cholecystectomy because of chronic cholecystitis. Patients had bile culture during surgery (January-December 2006). There were two study groups: patients with negative biliary culture (group 1) and patients with positive biliary culture (group 2). Variables were age, gender, biliary culture reports, abscess, cellulitis, seroma, and hematoma. Statistical analysis included Pearson chi(2) or Fisher's exact test. For independent variables, Student t-test was used. RESULTS: Eighty patients were included (n = 40 per group). There were 24 males (30%) and 56 females (70%) who had open cholecystectomy and had biliary culture. General morbidity was 42.50% and surgical site infection rate in general was 11.25%. There were two patients with abscesses and two patients with cellulitis in group 1. There were four patients with abscesses and one patient with cellulitis in group 2. There was no statistically significant difference when comparing surgical site infection in both groups. CONCLUSIONS: The presence of bacteria in gall bladder cultures does not correlate with the development of surgical site infection after open cholecystectomy.

Frequency of infected bile in patients of uncomplicated gallstone disease

To find out the association of bile infection with uncomplicated gallstone disease in our setup. A case control study. This study was carried out at Surgical Department Combined Military Hospital, Multan from 7th March 2007 to 15th September 2007. A total of 100 patients who underwent cholecystectomy for uncomplicated symptomatic cholelithiasis and 40 controls who underwent laparotomy and had no gallbladder stone shown by ultrasound scan, were included. Symptoms, clinical signs, findings of investigations, details of treatment and postoperative care were noted. Main focus of the study was aspiration of bile for culture peroperatively. The bile was sent for culture to assess microflora and their antibiotic susceptibility. The procedures were undertaken under sterile conditions. Out of 100, 30 bile culture positive cases for different micro-organisms were detected. Escherichia coli was found to be the commonest organism in our study [40%]. Next most common organism isolated was Klebsiella pneumoniae [23%]. There were no bacterial isolates in the bile of controls. The study demonstrated that patients with gallstone disease exhibit bactibilia in contrary to patients without gallstones who did not have bacteria in their bile, showing an association between gallstone formation and the presence of bacteria in bile

Asociación entre recuento bacteriano en la bilis y desarrollo de morbilidad postoperatoria en pacientes con colangitis aguda / Association between bile bacterial count and postoperative complications aniong patients with acute cholangitis

Background: Bacterial colonization of bile is common in patients with bile duct obstruction, even in the absence of clinical signs of sepsis. Aim: To determine the association between bile bacterial count and postoperative complications in patients with bile duct obstruction. Material and Methods: A bile bacterial count was performed to patients with acute cholangitis caused by biliary stones, operated between 2004 and 2006. Post operative complications and length of hospital stay were recorded in these patients. Results: Fifty four patients aged between 25 and 95 years (34 females) were studied. The most common bacteria found, were Escherichia coli in 32 cultures (50 percent), followed by Klebsiella pneumoniae in 6 cultures (9 percent). In 45 cases the bacterial load was over 10(5) colony forming units (CFU)/ml. Among patients with and without complications, 68 and 69 percent had a bacterial load over 10(5) CFU/ml, respectively (p = NS). A multivariate analysis showed an association between platelet count and prothrombin time with the incidence of complications. Conclusions: In this series of patients with acute cholangitis, no association between bile bacterial count and postoperative complications was observed.

Introducción: La colonización bacteriana de la bilis parece ser frecuente en pacientes con obstrucción de la vía biliar ya sea con o sin signos de sepsis. Objetivos: Determinar asociación entre el recuento bacteriano en la bilis de pacientes con colangitis aguda (CA) y el desarrollo de complicaciones postoperatorias; y, determinar asociación entre variables fisiológicas y desarrollo de complicaciones en el mismo grupo. Material y Método: Reporte preliminar de estudio de cohorte de pacientes con CA litiásica, intervenidos quirúrgicamente en los servicios de cirugía y urgencias del Hospital Regional de Temuco en el período diciembre de 2004 a noviembre de 2006. Se realizó cultivo cuantitativo y se registraron variables clínicas y de laboratorio al ingreso. Se efectuó medición de complicaciones postoperatorias, estancia hospitalaria y evolución de los pacientes. Se aplicó estadística descriptiva y posteriormente análisis univariado y multivariado. Resultados: Se estudió un total de 54 pacientes, 34 (63 por ciento) fueron de género femenino y 20 (37 por ciento) de género masculino, con una mediana de edad de 68 años (25 a 95 años). El germen más frecuentemente aislado fue Escherichia coli en 32 cultivos (50 por ciento), seguido por Klebsiella pneumoniae en 6 cultivos (9 por ciento). De los gérmenes aislados 45 (82 por ciento) tenían cargas bacterianas sobre 10(5) UFC/ml. De los pacientes que presentaron alguna complicación 68 por ciento tenían cargas bacterianas superiores a 10(5) UFC/ml y de los pacientes que no presentaron complicaciones 69 por ciento tenían cargas bacterianas inferiores a 10(5) UFC/ml (p = 0,513). En el análisis univariado se encontró asociación entre desarrollo de complicaciones y las variables frecuencia cardíaca, creatinina, recuento de plaquetas y tiempo de protrombina. Con el análisis multivariado se determinó asociación entre desarrollo de complicaciones y las variables recuento de plaquetas y tiempo de protrombina (OR: 4,35 y 4,58)...

Microflora of bile aspirates in patients with acute cholecystitis With or without cholelithiasis: a tropical experience

The current study determined the spectrum of biliary microflora with special emphasis on enteric fever organisms in patients with acute cholangitis with and without cholelithiasis or other biliary diseases. The patients were divided into three groups: Group A consisted of patients with acute cholecystitis with cholelithiasis; Group B consisted of patients with acute cholecystitis with gastrointestinal ailments requiring biliary drainage and group C consisted of patients with gallbladder carcinoma. Gallbladder, bile and gallstones were subjected to complete microbiological and histopathological examination. Antimicrobial susceptibility of the isolates was performed as per CLSI guidelines. Bacteria were recovered from 17 samples (32 percent) in Group A, 17 (51.4 percent) in Group B and 1 (1.6 percent) in Group C. The most common organisms isolated were Escherichia coli (11, 29.7 percent), Klebsiella pneumoniae (10, 27 percent), Citrobacter freundii (3, 8.1 percent), Salmonella enterica serovar Typhi (3, 8.1 percent), etc. The majority of Enterobacteriaceae isolates were susceptible to piperacillin-tazobactam and meropenem. As regards Salmonella spp., S. Typhi was isolated from 2 (3.8 percent) patients in Group A and 1 (16 percent) in Group C. Antimicrobial susceptibility of potential causative organisms, the severity of the cholecystitis, and the local susceptibility pattern must be taken into consideration when prescribing drugs. A protocol regarding the management of such cases should be formulated based on observations of similar studies.

Microbiologic Study of the Bile Culture and Antimicrobial Susceptibility in Patients with Biliary Tract Infection / 대한소화기학회지

BACKGROUND/AIMS: Bacterial infection of biliary tract may cause severe inflammatory response or sepsis. An immediate bile culture and appropriate antibiotic administration are important to control the biliary tract infection. The objective of the study was to identify organisms in bile and the features of antibiotic susceptibility in patients with biliary tract infection. METHODS: We retrospectively reviewed the clinical records of 212 patients whose bile had been cultured for variable biliary tract diseases at Inje University Ilsan Paik Hospital from Jan. 2000 to Feb. 2007. Bile samples were obtained from percutaneous transhepatic biliary drainage (PTBD, n=89), percutaneous transhepatic gallbladder drainage (PTGBD, n=14) or endoscopic naso-biliary drainage (ENBD, n=49). RESULTS: The overall positive rate of bile culture was 71.7% (152 cases). The organisms cultured were Escherichia coli (25.0%), Enterococcus spp. (13.4%), Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) in decreasing order. Effective antibiotics for Gram-negative organisms were amoxicillin/clavulanic acid, amikacin, imipenem, and piperacillin/tazobactam in order of effectiveness. Of the cultured blood samples from 160 patients, fifty (31.2%) showed positive bacterial growth. The organisms isolated from blood were similar to those found in the bile. CONCLUSIONS: A broad spectrum penicillin/beta-lactamase inhibitor is a recommendable antimicrobial for empirical treatment for biliary tract infection. However, Gram-positive bacteria such as Enterococcus spp. or methicillin-resistant Staphylococcus aureus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

Patología obstructiva de la vía biliar: análisis bacteriológico / Patología obstructiva de la vía biliar: análisis bacteriológico

Introducción: La infección del árbol biliar constituye una de las complicaciones más serias que afectan a pacientes con patología hepatobiliopancreática. El estudio bacteriológico de la bilis, sumado a la fisiopatología de obstrucción canalicular y su realización con diferentes parámetros, permite instrumentar mediante la confección de protocolos de procedimientos, distintas conductas terapéuticas. Objetivo: Analizar nuestra experiencia en el estudio bacteriológico de la bilis en los enfermos con patología obstructiva canalicular. Lugar de aplicación: Práctica hospitalaria y extrahospitalaria. Diseño: Observacional retrospectivo. Material y métodos: Entre julio de 2002 y febrero de 2003, se analizaron 97 pacientes con Síndrome de Hipertensión canalicular de diversa etiología. En todos los casos se efectúo drenaje percutáneo de la vía biliar como tratamiento de la obstrucción canalicular y se obtuvo, como primer gesto, bilis para cultivo y antibiograma. Resultados: El análisis de las muestras enviadas a cultivo demostró desarrollo bacteriano en el 42,2% de los pacientes (41 cultivos positivos). Los cultivos fueron positivos en el 37,5% de los pacientes con patología maligna (30 casos). Se obtuvo desarrollo bacteriano en el 65% de los pacientes con enfermedad benigna (11 casos), siendo la Klebsiella el micro organismo más frecuente, seguido de enterococo y E. coli. El 41% de los pacientes con Tumor de Klatskin tuvieron cultivos positivos. Por otra parte, en el 86% de los pacientes con instrumentación biliar percutánea previa, el cultivo fue positivo para enterococo y E. coli. Conclusión: Consideramos que ante un paciente con patología obstructiva de la vía biliar de cualquier etiología en quien se efectúa una instrumentación percutánea debe realizarse profilaxis antibiótica y antibioticoterapiagía en quien se fectúa una instrumentación percutánea debe realizarse profilaxis antibiótica y antibioterapia inicial en los grupos de riesgo...

Usefulness of Bile Cultures and Predictive Factors for Bacteriobilia in Percutaneous Cholecystostomy in Patients with Acute Cholecystitis / 대한진단검사의학회지

BACKGROUND: Bile cultures have been used to diagnose and predict the prognosis of acute cholecystitis (AC). As the standard treatment for AC has changed, the appropriate timing and clinical usefulness of bile cultures should be reevaluated. We analyzed the incidence of positive bile cultures in cholecystostomy and cholecystectomy, and attempted to see if a positive bile culture is related to the laboratory and imaging parameters and postoperative infections. METHODS: Included in the study were 86 patients with AC who underwent percutaneous cholecystostomy (PC) and then laparoscopic cholecystectomy (LC). We performed hematologic, biochemical, and radiological analyses at admission and bile cultures with each surgical procedure. The patients were followed for two months for postoperative infections. RESULTS: Bile cultures were positive in 40.7% of the patients at PC, significantly higher than at LC (12.8%). The group with positive cultures showed a higher median age and elevated levels of alkaline phosphatase (ALP) and total bilirubin (TB) than the group with negative cultures. Univariate analysis identified three preoperative factors as predictors of positive bile cultures: age (>55 yr), ALP (>100 IU/L) and TB (>1.2 mg/dL). Infectious complications after LC were mild and the incidence of postoperative infections was not different between the groups. CONCLUSIONS: The sensitivity of bile cultures is low for diagnosing AC, and the adequate timing of bile cultures is at PC, rather than LC. An old age and factors (ALP & TB) manifesting an advanced stage of bile stasis are associated with positive bile cultures. No correlation was found between positive bile cultures and postoperative infections.

Usefulness of Bile Cultures and Predictive Factors for Bacteriobilia in Percutaneous Cholecystostomy in Patients with Acute Cholecystitis / 대한진단검사의학회지

BACKGROUND: Bile cultures have been used to diagnose and predict the prognosis of acute cholecystitis (AC). As the standard treatment for AC has changed, the appropriate timing and clinical usefulness of bile cultures should be reevaluated. We analyzed the incidence of positive bile cultures in cholecystostomy and cholecystectomy, and attempted to see if a positive bile culture is related to the laboratory and imaging parameters and postoperative infections. METHODS: Included in the study were 86 patients with AC who underwent percutaneous cholecystostomy (PC) and then laparoscopic cholecystectomy (LC). We performed hematologic, biochemical, and radiological analyses at admission and bile cultures with each surgical procedure. The patients were followed for two months for postoperative infections. RESULTS: Bile cultures were positive in 40.7% of the patients at PC, significantly higher than at LC (12.8%). The group with positive cultures showed a higher median age and elevated levels of alkaline phosphatase (ALP) and total bilirubin (TB) than the group with negative cultures. Univariate analysis identified three preoperative factors as predictors of positive bile cultures: age (>55 yr), ALP (>100 IU/L) and TB (>1.2 mg/dL). Infectious complications after LC were mild and the incidence of postoperative infections was not different between the groups. CONCLUSIONS: The sensitivity of bile cultures is low for diagnosing AC, and the adequate timing of bile cultures is at PC, rather than LC. An old age and factors (ALP & TB) manifesting an advanced stage of bile stasis are associated with positive bile cultures. No correlation was found between positive bile cultures and postoperative infections.

Frequency of infection in cholelithiasis

To determine the frequency of infection in cholelithiasis and find common infecting organisms with their antibiotic sensitivity. A descriptive study. This study was conducted in Surgical Unit - I, Jinnah Postgraduate Medical Centre [JPMC], Karachi, Pakistan, from April 2001 to March 2002. First 100 cases of cholelithiasis, selected and operated by open or laparoscopic cholecystectomy were included in this study. Patients with acute cholecystitis, history of jaundice, stones and / or dilated common bile duct were excluded from the study. Ultrasound was the main tool for pre-operative diagnosis. During cholecystectomy, bile was aspirated and specimens were sent to laboratory for microbiological examination. The results were recorded on a proforma. Out of 100, 36 patients had positive bile culture. The most common organism was E. coli [17 patients] followed by Klebsiella [9], Pseudomonas [6], Staphylococcus aureus [2], Salmonella [1] and Bacteroids fragalis [1] patient. In this study, most of the biliary organisms were highly sensitive to the 2nd generation cephalosporins and quinolones. From the bacteriological assessment, it seems that both endogenous and exogenous contamination were the causes of wound sepsis. It was also found that the infection of bile did not increase the risk of postoperative wound infection when prophylactic perioperative antibiotics were used

Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs / Efeitos da lesão estrutural na contaminação bacteriana biliar após a esfincteroplastia transduodenal (dilatação papilar) em cães

PURPOSE: To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). Blood samples collected on times t(0day), t(7days) and t(28days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction. RESULTS: The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0

OBJETIVO: Avaliar, em cães, a papila duodenal maior submetida à dilatação por balão hidrostático sob o ponto de vista das alterações estruturais da papila e da bioquímica e contaminação bacteriana da bile. MÉTODOS: Vinte cães foram submetidos a laparotomia, duodenotomia, dilatação da papila maior GA (n=10) - com balão de 8mm insuflado com pressão de 0,5atm, durante 2 minutos ou ao procedimento simulado - GB(n=10). Amostras de sangue coletadas nos tempos t(0dia), t(7dias) e t(28dias) foram submetidas às dosagens da fosfatase alcalina (FA) e gama-glutamil-transferase (GGT) para avaliação da colestase. Material colhido da vesícula biliar nos mesmos tempos foi registrado e numerado para ser submetido à cultura em BHI, ágar sangue (meio rico não seletivo), e Mac Conkey (meio seletivo para bacilos Gram-negativos). No 28°. dia três fragmentos da papila forma cortados transversalmente ao eixo do colédoco a 3mm da papila duodenal e os cortes corados em hematoxilina-eosina e tricômio de Masson e avaliados quanto a reação inflamatória. RESULTADOS: As médias da GGT e da FA nos três períodos nos grupos A e B não mostraram diferenças significantes, não sendo caracterizada a colestase. A contaminação bacteriana foi significante maior em GA(2,19) que no GB(1,96); a contaminação foi menor no tempo inicial em relação aos 7 e 28 dias( t0

Aerobic bacterial isolates from choledochal bile at a tertiary hospital.

We studied the aerobic bacterial isolates from bile and their susceptibilty pattern in patients with biliary tract disease. Samples of bile collected during endoscopic retrograde cholangio pancreatography (ERCP) and surgery, were inoculated on standard media. Bacterial identification and susceptibility were done by standard techniques. A total of 209 samples were cultured, out of which 128 samples showed growth. Total number of isolates obtained was 221. Poly-microbial infection was detected in 67 patients. Predominant aerobic bacterial isolates obtained were Escherichia coli 30% (67), Klebsiella species 23.98% (53), Enterococcus species 12.21% (27). Multi-drug resistance was noted in 57%. Higher resistance rate was noted among Gram negative bacilli for ampicillin (92.4%), cephalexin (82.46%), ciprofloxacin (68.42%), piperacillin (64.33%). Sensitivity to meropenem was 90.64% and amikacin was 76.61%. Gram positive bacteria showed high resistance to gentamicin (39.53%). Sensitivity to ampicillin was 86.05% and penicillin was 81.4%. Vancomycin and teicoplanin showed 100% sensitivity. From our study we conclude that E. coli, Klebsiella species and Enterococcus species are common pathogens infecting biliary tract. Poly-microbial infection and multi-drug resistance warrants culture and sensitivity to guide antimicrobial therapy. We recommend combination of amikacin and ampicillin for empirical therapy at our institution.

Estimation of endotoxin in infected bile from patients with biliary diseases.

Diseases of the biliary tract can get complicated by infection. Endotoxin may theoretically be responsible for damage to the gall bladder due to its numerous pathophysiological effects. The aim of the present study was to detect and semi-quantitate the amount of endotoxin present in the bacteriologically positive bile samples and to correlate the endotoxin levels with the clinical profile of the patients. One hundred patients with gall bladder diseases and with infected bile constituted the population for investigation. The clinical profile included presence of fever, jaundice, abdominal pain and gall bladder stones. Endotoxin detection and semi-quantitation in the bile samples were carried out using the Limulus amoebocyte assay: Of 100 infected bile samples investigated, 9 samples (9%) were positive for endotoxin ranging from 1.9 EU/ml to 15 EU/ml. Four of them had Klebsiella pneumoniae, 2 had Acinetobacter anitratus and one each of the remaining 3 samples was positive for (i) Escherichia coli and Serratia marcescens (ii) Pseudomonas aeruginosa and (iii) Salmonella enteritidis. The stool sample of the patient with S. enteritidis in the bile also grew the same microorganism. Statistical analysis showed a significant increase in the presence ofjaundice (p<0.05) and abdominal pain (p<0.01) in the endotoxin positive patients compared to the endotoxin negative ones. Hitherto this is the first report that investigated the endotoxin levels in the bile of patients with gall bladder and biliary tract diseases, along with their biliary bacterial profile. Further research is warranted on the effects of endotoxin on gall stone formation.

Bile cultures and sensitivity patterns in malignant obstructive jaundice.

BACKGROUND: Bactibilia is one of the important factors in the development of postoperative septic complications. We undertook this retrospective analysis to identify the organisms present in bile and their antibiotic susceptibility patterns in patients with malignant obstructive jaundice. METHODS: Bile specimens were obtained during endoscopic cholangiography (ERC; n=65), by flushing biliary stents (n=15), intra-operatively before incising the common bile duct (n=7) or during percutaneous transhepatic biliary drainage (PTBD; n=1). Eighty-eight samples from 65 consecutive patients were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant septic complications such as wound infection and cholangitis were also assessed. RESULTS: Of 65 patients (hilar block 39, distal block 26), 17 (26.1%) had bactibilia at initial ERCP; in addition, 3 of 7 bile specimens obtained during surgery, one collected during PTBD, and 13 of 15 stent flushings grew bacterial organisms. Cholangitis developed in 15 patients (12 with hilar block, 3 with distal block). Blood cultures were positive in 3 cases, and initial bile culture was positive in four patients with cholangitis. The most commonly found organisms were Escherichia coli (36.6%), Klebsiella pneumonia (18.3%), Pseudomonas aeruginosa (8.3%), Proteus vulgaris (8.3%) and coagulase-negative staphylococci (8.3%). The organisms found on ERC were similar to those found at wound cultures in 3 of the 4 cases who developed wound infection. Amikacin, gentamicin, cefotaxime, ceftazidime, and cefoperazone-sulbactam combination showed good activity against E. coli and K. pneumonia. CONCLUSION: Approximately one-fourth of patients with malignant obstructive jaundice have positive bile cultures at initial ERC. Post-ERC cholangitis is common in hilar blocks.

Tissue plasminogen activator and plasminogen activator inhibitor-1 in human choledochal bile

Fibrinolytic properties have been detected in animal and human gallbladder (GB) bile. Plasminogen activator inhibitor-1 (PAI-1) has been reported in greater concentration in GB stone bile and may be a nucleating factor in the pathogenesis of GB stone formation. It is unknown whether or not human choledochal bile has similar properties, which could have a role in choledocholithiasis. The aims of this study were to determine the presence of fibrinolytic properties of human choledochal bile and to compare those properties among normal, acalculous, and calculous-infected choledochal bile. Tissue plasminogen activator (t-PA) and PAI-1 of choledochal bile were measured by enzyme linked immunosorbent assay in patients with cholangitis due to acalculous bile duct obstructions (n = 9), choledocholithiasis with cholangitis (n = 20), and normal bile (n = 7). The t-PA concentration of choledochal bile was no different among the three groups (acalculous-infected bile, median 4.61 ng/ml, and calculous-infected bile, 4.61 ng/ml, versus normal bile, 7.33 ng/ml). PAI-1 was detected in choledochal bile in significantly greater concentrations in patients with acalculous cholangitis due to bile duct obstructions and choledocholithiasis with cholangitis (acalculous-infected bile, median 0.36 ng/ml, and calculous-infected bile, 0.1 ng/ml, versus normal bile, 0.02 ng/ml, p < 0.05), but the bile concentration of PAI-1 was no different between the acalculous and calculous-infected choledochal bile. Human choledochal bile possesses t-PA and PAI-1. PAI-1 was present in greater concentrations in both acalculous and calculous-infected choledochal bile. Increased levels of PAI-1 may be an epiphenomenon of cholangitis rather than a factor in the pathogenesis of choledocholithiasis.

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.