Long-term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis.

BACKGROUND AND AIM: Percutaneous cholecystostomy (PC) has been frequently used as an alternative treatment for acute cholecystitis in seriously ill patients unfit for surgery. The aim of this study was to investigate the recurrence rate and risk factors of recurrence. METHODS: Medical records of 102 patients who were followed up for more than 1 year after PC tube removal among 716 patients who underwent PC for acute cholecystitis treatment were retrospectively analyzed. RESULTS: The recurrence rate of acute cholecystitis after PC tube removal was 20.6% (21/102), and the mean time to recur was 660 days. Underlying cancer (odds ratio [OR]: 3.369; 95% confidence interval [CI]: 1.006-11.282; P = 0.0489), PC duration shorter than 44 days (OR: 5.596; 95% CI: 1.35-23.201; P = 0.0176), and the presence of common bile duct stone in initial imaging studies (OR: 24.393; 95% CI: 2.696-220.746; P = 0.0045) were positively correlated with recurrence. Tubogram before PC tube removal did not significantly lower the recurrence. However, PC tube clamping for several days significantly lowered the recurrence (OR: 0.108; 95% CI: 0.015-0.794; P = 0.0288). Fifty-nine (57.8%) had acalculous cholecystitis. Calculous cholecystitis was negatively correlated with recurrence (OR: 0.267; 95% CI: 0.074-0.967; P = 0.0444). Receiver operating characteristic curve of the prediction model for recurrence verified its accuracy (area under the curve: 0.8475). CONCLUSION: We should try to keep PC more than 6 weeks and clamp for 1-2 weeks before removal. For those with the presence of common bile duct stones, calculous cholecystitis, and underlying malignancy, we should keep PC for longer duration and carefully observe symptoms and signs of recurrence.

Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.

Clinical Characteristics and Outcomes of Pyogenic Liver Abscess in Elderly Korean Patients.

BACKGROUND/AIMS: Incidence of pyogenic liver abscess (PLA) has been increasing worldwide, especially in the elderly population. Therefore, the aim of this study is to elucidate the clinical features and outcomes of PLA in elderly patients. METHODS: A total of 602 patients diagnosed with PLA from January 2003 to January 2013 were analyzed retrospectively. The patients were divided according to two age groups;≥ 65 years (n=296) and <65 years (n=306). RESULTS: The mean age was 73.59 ± 5.98 (range, 65-93) years in the elderly group. Significantly higher incidence of females (52.4% vs. 29.1%, p<0.001), hepatobiliary disease (41.2% vs. 24.8%, p<0.001), hepatobiliary procedure (29.4% vs. 13.7%, p<0.001), underlying malignancy (18.2% vs. 4.6%, p<0.001), culture positivity of resistant organism (20.6% vs. 14.4%, p=0.047), occurrence of complication (19.6% vs. 12.8%, p=0.026), and higher white blood cell (13.44 ± 6.56 vs. 12.26 ± 5.89, p=0.021), but lower rates of right lobe abscess (67.2% vs. 80.4%, p<0.001), fever (68.6% vs. 79.3%, p=0.003), and lower CRP (16.79 ± 9.67 vs. 18.80 ± 9.86, p=0.012) was observed in elderly PLA patients, compared to younger patients. Regarding complications, elderly patients had higher incidence of septic shock (8.1% vs. 2.3%, p=0.001) and cardiovascular disease (2% vs. 0%, p=0.014). CONCLUSIONS: More atypical presentations and complications tend to occur in elderly PLA patients compared with younger patients. Clinicians should be aware of these age-related differences in PLA and devise management strategies accordingly.

Prevalence of and risk factors for endogenous endophthalmitis in patients with pyogenic liver abscesses.

BACKGROUND/AIMS: Although pyogenic liver abscesses (PLAs) can be successfully treated, the visual prognosis of patients with endogenous endophthalmitis (EE) associated with a PLA is poor. Early diagnosis and prompt intervention may salvage useful vision. Therefore, we investigated risk factors for EE in patients with PLA, to facilitate early diagnosis. METHODS: Data from 626 patients diagnosed with PLA between January 2004 and July 2013 were analyzed retrospectively. Patients were divided into two groups: those with liver abscess-associated endogenous endophthalmitis (LAEE) and non-LAEE. RESULTS: The prevalence of EE in PLA patients was 1.92%. The mean age for all patients (373 males, 59.6%) was 62.8 years. Upon multivariate logistic regression, a liver abscess or another systemic infection (odds ratio [OR], 5.52; p = 0.005), an abscess in the right superior segment (OR, 5.26; p = 0.035), and Klebsiella pneumoniae infection (OR, 3.68; p = 0.039), were risk factors for LAEE. The final visual outcomes of patients with LAEE included no light perception in seven, hand motion only in three, and decreased visual acuity in two. Vitrectomy and early intravitreal injections of antibiotics improved visual acuity and preserved useful vision. CONCLUSIONS: PLA patients with other systemic infections, abscesses in the right superior segment, and K. pneumoniae infection require close monitoring and early intervention to treat LAEE. Intravitreal antibiotic injections or early vitrectomy may salvage useful vision.

Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess.

OBJECTIVE: To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA). METHODS: A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA). RESULTS: The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%. CONCLUSION: Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA.