Effect of preoperative biliary drainage on intraoperative biliary cultures and surgical outcomes after pancreatic resection.

BACKGROUND: Prolonged obstructive jaundice (OJ), associated with resectable pancreatic pathology, has many deleterious effects that are potentially rectifiable by preoperative biliary drainage (POBD) at the cost of increased postoperative infective complications. The aim of this study is to assess the impact of POBD on intraoperative biliary cultures (IBCs) and surgical outcomes in patients undergoing pancreatic resection. METHODS: Data from patients at Groote Schuur Hospital, Cape Town, between October 2008 and May 2019 were analysed. Demographic, clinical, and outcome variables were evaluated, including perioperative morbidity, mortality, and 5-year survival. RESULTS: Among 128 patients, 69.5% underwent POBD. The overall perioperative mortality in this study was 8.8%. The POBD group had a significantly lower perioperative mortality rate compared to the non-drainage group (5.6% vs. 25.6%). POBD patients had a higher incidence of surgical site infections (55.1% vs. 23.1%), polymicrobial growth from IBCs and were more likely to culture resistant organisms. Five-year survival was similar in the two groups. CONCLUSION: POBD was associated with a high incidence of resistant organisms on the IBCs, a high incidence of surgical site infections and a high correlation between cultures from the surgical site infection and the IBCs.

Predicting Inchinkoto efficacy, in patients with obstructive jaundice associated with malignant tumors, through pharmacomicrobiomics.

Inchinkoto (ICKT) is a popular choleretic and hepatoprotective herbal medicine that is widely used in Japan. Geniposide, a major ingredient of ICKT, is metabolized to genipin by gut microbiota, which exerts a choleretic effect. This study investigates the relationship between stool genipin-producing activity and diversity of the clinical effect of ICKT in patients with malignant obstructive jaundice. Fifty-two patients with malignant obstructive jaundice who underwent external biliary drainage were included. ICKT was administered as three packets per day (7.5 g/day) for three days and 2.5 g on the morning of the fourth day. Stool samples were collected before ICKT administration and bile flow was monitored on a daily basis. The microbiome, genipin-producing activity, and organic acids in stools were analyzed. The Shannon-Wiener (SW) index was calculated to evaluate gut microbiome diversity. The stool genipin-producing activity showed a significant positive correlation with the SW index. Stool genipin-producing activity positively correlated with the order Clostridia (obligate anaerobes), but negatively correlated with the order Lactobacillales (facultative anaerobes). Moreover, stool genipin-producing activity was positively correlated to the concentration valeric acid, but negatively correlated to the concentration of lactic acid and succinic acid. The change of bile flow at 2 and 3 days after ICKT administration showed significant positive correlation with genipin-producing activity (correlation coefficient, 0.40 and 0.29, respectively, P < 0.05). An analysis of stool profile, including stool genipin-producing activity, may predict the efficacy of ICKT. Modification of the microbiome may be a target to enhance the therapeutic effect of ICKT.

Obstructive jaundice: Studies on predictors of biliary infection and microbiological analysis in an HIV setting.

BACKGROUND: Early diagnosis of biliary infection is critical for timely antimicrobial therapy and biliary drainage. HIV infection may influence the spectrum and severity of biliary infection in an environment with a high HIV prevalence. Charcot's triad has low sensitivity and higher specificity for biliary infection, and more sensitive markers are required. OBJECTIVES: To investigate possible predictors of biliary infection (bacteriobilia) and identify the microbiological spectrum in patients presenting with biliary obstruction to a tertiary institute in an environment with a high prevalence of HIV. METHODS: Bile was assessed for infection at endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and surgery, and the roles of clinical/haematological factors, C-reactive protein (CRP) and procalcitonin (PCT) in determining biliary infection were evaluated. RESULTS: One hundred and six patients with obstructive jaundice had a mean age of 52 years (range 21 - 58); most were female (74%), and 36 (34%) were infected with HIV, with a mean CD4 count of 495 cells/µL. Choledocholithiasis (53%), biliary strictures (21%) and head of pancreas tumour (8%) were the main aetiopathologies. Bile was obtained for microbial culture from 104 patients (98%), and 56 (54%) were infected. Gram-negative bacteria were most frequent (58%), and 2 HIV-infected patients had fungal infections (Candida albicans and Aspergillus fumigatus). Screening for endoscopy-associated infections revealed Pseudomonas aeruginosa. PCT was a poor predictor of bacterial infection, whereas CRP was a fair predictor. CONCLUSIONS: The majority of bacteria cultured were sensitive to ciprofloxacin or amoxicillin-clavulanate. Duodenoscopes were a potential source of Pseudomonas infection.

A case of tuberculosis presented by obstructive jaundice tuberculosis-related mechanical icterus.

Obstructive jaundice caused by tuberculosis lymphadenitis is a rare condition. It can mimic clinical and radiological findings of hepatobiliary malignancies. The authors report a 24-year-old male patient who presented with abdominal pain, fever and jaundice for the last two weeks. It was found that cholestasis enzymes were increased by 2-3 fold and direct bilirubin was 6.13 mg/dL. Imaging studies revealed conglomerated lymph nodes with some cavitary lesions and dilated intrahepatic biliary canal secondary to compression by the lymph nodes. Tuberculosis was found to be positive in the polymerase chain reaction analysis of the aspirate that was obtained in the guidance of imaging studies. M. tuberculosis complex was isolated from mycobacterial culture. Anti-tuberculosis treatment was initiated. Clinical, laboratory and radiological findings completely resolved by medical therapy alone. Tuberculosis lymphadenitis should be kept in mind in cases presenting with obstructive jaundice in endemic areas and interventional diagnostic techniques should be preferred in eligible patients.

Syphilitic pancreatitis: A rare mimicker of our time.

We present an unusual case of syphilitic pancreatitis and ascending aortitis in a 41-year-old HIV-negative male patient presenting to a tertiary institution with obstructive jaundice. After a battery of investigations that included computed tomography (CT) and 18F-labelled fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) imaging, syphilis serology and histology, a diagnosis of tertiary syphilis was made. The patient responded favourably to antibiotics, with resolution of all lesions on FDG PET/CT 13 weeks after initiation of therapy. Even though tertiary syphilis is a rare entity, it should be earmarked as a mimicker of other pathological conditions, including, in this case, primary pancreatic malignancy.

Obstructive jaundice of a parasitic etiology

No disponible

Combined Effectiveness of Honey and Immunonutrition on Bacterial Translocation Secondary to Obstructive Jaundice in Rats: Experimental Study.

BACKGROUND Obstructive jaundice is a serious, life-threatening condition that can lead to death as a result of sepsis and multiorgan failure due to bacterial translocation. Treatment should be started as soon as possible after diagnosis. MATERIAL AND METHODS Forty 24-week-old male Sprague Dawley rats, with an average weight of 250 g to 300 g, were included in this study. The rats were randomly placed into five groups, each group consisted of eight rats. The sham group underwent only common bile duct (CBD) dissection and no ligation was performed. CBD ligation was applied to the other groups. After the operation, one CBD group was fed with rat chow only, the others were fed with rat chow supplemented with honey, or immunonutrients, or honey plus immunonutrients. After 10 to 12 days, all rats were sacrificed; blood and tissue samples were collected for biochemical, microbiological, and histopathological evaluation. RESULTS In the groups that were fed with honey and immunonutrients, alanine aminotransferase (ALT) levels were decreased significantly compared to the other groups. Statistically significant differences were detected in terms of bacterial translocation (BT) rates among liver and spleen samples, and laboratory values of serum, except for MLNs of the BDL+HI group, when compared to other groups. We found mean mucosal thickness of ileum samples have been improved notably in the BDL+HI group compared to the other groups, especially compared to the C/BDL group. CONCLUSIONS Immunonutrition applied with honey had immunostimulant effects, decreased BT due to an additive effect, and had positive effects on intestinal mucosa.

Pathophysiological consequences of obstructive jaundice and perioperative management.

BACKGROUND: Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management. DATA SOURCES: A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated. RESULTS: The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases. CONCLUSION: The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

"Primary bacterial culture of bile and pancreatic juice in tumor related jaundice (TROJ) - is ascending cholangitis always our fault?"

INTRODUCTION: TROJ (tumor-related obstructive jaundice) is one of the most common indications for endoscopic retrograde choleopancreatography (ERCP) with endoscopic biliary stenting. Despite the effectiveness of this procedure, especially in palliative patients, it is not without flaws. Ascending bacterial cholangitis, a common stenting complication, occurs in about 0.5-1.7% of cases. The authors' intention was to investigate whether this complication occurs solely due to the procedure or whether it is a result of an underlying bacterial infection in the dilated, obstructed bile and pancreatic ducts. METHODS: Sixteen patients with painless obstructive jaundice related to a tumor located in or in the proximity of the bile duct were enrolled for this study. Prior to endoscopic palliative stenting we harvested bile and pancreatic fluid and the proceeded with the initial procedure. RESULTS: In 14 cases (87.5%) we managed to restore the patency of the bile duct endoscopically. Additionaly, we observed that in 13 cases (81.25%) bacteria were present in the bile and/or pancreatic fluid. The most common pathogen was Streptococcus mitis - present in 7 cases (43.75%). The most effective antibiotics for discovered S. mitis strains were cefuroxime and vancomycin. CONCLUSION: Primal bacterial pathogenes may be present in obstructed bile and pancreatic ducts prior to endoscopic intervention. The connection between Streptocccus mitis and TROJ needs further investigation.

Cryptococcosis manifesting as isolated biliary infection: Case report and brief review of literature.

BACKGROUND: Biliary cryptococci infection is rare, which is frequently diagnosed by exploratory laparotomy, preoperative diagnosis is difficult. CASE PRESENTATION: A 14-year-old girl presented with intermittent jaundice for 6 years. She had no pruritus, anorexia, nausea or vomiting, fever, abdominal pain, or clay stools. Laboratory tests showed obstructive jaundice, eosinophilia, and increased IgE levels. The patient was ultimately diagnosed as Cryptococcal infection by bone marrow culture. The patient responded to antifungal therapy. CONCLUSION: Unnecessary surgical intervention was avoided by an early and accurate diagnosis. Cryptococcosis infection of bile duct should be highly suspected, when the children with obstructive jaundice have eosinophilia and increased IgE levels.

[MORPHOLOGICAL CHANGES OF THE LIVER IN OBTURATION JAUNDICE, CAUSED BY CHOLEDOCHOLITHIASIS, DEPENDING ON ITS DURATION].

Abstract The results of surgical treatment of 184 patients for obturation jaundice, caused by choledocholithiasis, were analyzed. Morphological changes of the liver were studied in 20 patients. There were three groups of patients delineated, depending on the obturation jaundice duration: up to 7 days, from 8 to 14 days, more than 15 days, and also a group of patients after the bile outflow restoration. The obturation jaundice occurrence in choledocholithiasis is accompanied by significant morphological changes in the liver, severity of which is enhancing while the obturation jaundice persistence increasing. While persistence of obturation jaundice through 8 days and more the connective tissue volume is enhancing, a relative volume of hepatocytes is reducing and a stromal-parenchymatous index is increasing. The bile outflow restoration secures significant reduction of intensity of alterative and inflammatory changes in hepatic parenchyma, as well as activation of reparative processes in the tissue. In cholangitis, caused by P. aeruginosa and E. coli, according to morphological investigations data, in the liver a diffuse purulent cholangitis on background of chronic changes in accordance to duration of the obturation jaundice persists.

[CLINIC-EXPERIMENTAL SUBSTANTIATION OF OZONOTHERAPY APPLICATION IN THE TREATMENT OF PURULENT CHOLANGITIS AND OBTURATION JAUNDICE].

Efficacy of the ozonotherapy application as an important component of complex treatment in purulent cholangitis (PCH) was studied. In choledocholithiasis (without infectioning of bile) ozonotherapy may be prescribed as additional component at complex treatment. In PCH ozonotherapy application have promoted the improvement of laboratory indices in 6.6 times, comparing with such, occurring after basic therapy.

The effects of erythropoietin on bacterial translocation and inflammation in rats with obstructive jaundice.

INTRODUCTION: Obstruction of the common bile duct is associated with hepatic paranchymal damage and increased susceptibility to subsequent bacterial infections. Erythropoietin has antiinflammatory and cytoprotective effects and it induces antiinflammatory cytokines and suppresses the production of proinflammatory cytokines. In this study, we aimed to investigate the effect of Erythropoietin on bacterial translocation, inflammation and tissue damage in rats with obstructive jaundice. MATERIALS AND METHODS: Thirty-two Wistar albino rats (200-250 g) were divided into 4 groups as follows: Group 1 (Sham); only hepatoduodenal ligament dissection, Group 2 (Erythropoietin); hepatoduodenal ligament dissection and given 500 IU/kg Erythropoietin subcutaneously, Group 3 (Obstructive jaundice); complete hepatoduodenal ligament ligation, Group 4 (Obstructive jaundice + Erythropoietin); complete hepatoduodenal ligament ligation and given 500 IU/kg Erythropoietin subcutaneously. After 7 days, the rats were sacrificed by taking blood from the heart for biochemical analyses. Peritoneal swab culture, liver, mesenteric lymph nodes, spleen and ileum were collected for microbiological and histopathological examinations. RESULTS: Erythropoietin reduced the secretion of inflammatory cytokines, oxidative damage and bacterial translocation, prevent the formation of inflammatory changes in intestine and liver after obstructive jaundice. CONCLUSION: The treatment of EPO in rats with OJ reduces bacterial translocation, inflammation and tissue damage.

The diagnostic value of C-reactive protein in bacterial translocation in experimental biliary obstruction.

BACKGROUND: Many experimental studies have verified that obstructive jaundice (OJ) causes bacterial translocation (BT). OBJECTIVES: The aim of this study was to assess to whether C-Reactive Protein (CRP) can be used to detect bacterial translocation induced by biliary obstruction. MATERIAL AND METHODS: Twenty rats were divided into two groups containing 10 rats each: sham-operated controls and the obstructive jaundice (OJ) group. All procedures were performed aseptically. After an upper midline incision, the common bile duct (CBD) was identified, mobilized, ligated and divided. The sham-operated animals had a similar incision, followed by mobilization of the CBD, without ligation or division. Ten days after the first operation, a second laparotomy was performed. Blood samples were collected for culture and serum CRP analysis. In addition, liver, spleen, and mesenteric lymph node (MLN) specimens were taken for microbiological culture to determine the presence of BT. BT was considered positive if there was any bacterial growth in the MLN, liver, spleen, or blood cultures; a lack of bacterial growth indicated a negative BT. RESULTS: The OJ group had significantly higher rates of bacterial translocation than the sham-operated group (p = 0.002). Mean CRP levels (ng/mL) were 8.7 ± 11.8 and 18.6 ± 17.2 in the sham-operated group and the OJ group respectively. There was no significant difference in mean CRP levels between the two groups (p = 0.257). Mean CRP levels were 4.5 ± 4.3 and 24.9 ± 16.4 in the BT (-) and BT (+) groups respectively (p = 0.003). A marked increase in CRP levels paralleled an increase in BT. CONCLUSIONS: This study has demonstrated a direct relationship between BT and CRP levels in an experimental OJ model.

Isolated hepatobiliary cryptococcosis manifesting as obstructive jaundice in an immunocompetent child: case report and review of the literature.

The majority of patients with symptomatic cryptococcosis have an underlying immunocompromising condition. In the absence of coexisting immunocompromising condition, Cryptococcus neoformans is rarely considered in the differential diagnosis of obstructive jaundice that occurs in children with hilar masslike lesion. Here, we report a 5-year-old boy without immunoglobulin or lymphocyte abnormalities who developed a hepatobiliary infection with C. neoformans. Ultrasonography and computed tomography showed dilatation of the bilateral intrahepatic bile ducts and a low-attenuated mass in the hepatic hilum. Microscopic examination of tissue samples revealed abundant numbers of encapsulated yeast cell suggestive of C. neoformans. After 4 months of antifungal therapy (liposomal amphotericin B for 2 weeks and oral fluconazole for 3 months), the disease was effectively controlled. Unnecessary operation could be avoided by an early and accurate diagnosis. By sharing our experience, we suggest hepatobiliary surgeons and gastroenterologists should have a suspicion of this unusual entity to make earlier diagnosis and treatment.

Antimicrobial-related severe adverse events during treatment of bone and joint infection due to methicillin-susceptible Staphylococcus aureus.

Prolonged antimicrobial therapy is recommended for methicillin-susceptible Staphylococcus aureus (MSSA) bone and joint infections (BJI), but its safety profile and risk factors for severe adverse events (SAE) in clinical practice are unknown. We addressed these issues in a retrospective cohort study (2001 to 2011) analyzing antimicrobial-related SAE (defined according to the Common Terminology Criteria for Adverse Events) in 200 patients (male, 62%; median age, 60.8 years [interquartile range {IQR}, 45.5 to 74.2 years]) with MSSA BJI admitted to a reference regional center with acute (66%) or chronic arthritis (7.5%), osteomyelitis (9.5%), spondylodiscitis (16%), or orthopedic device-related infections (67%). These patients received antistaphylococcal therapy for a median of 26.6 weeks (IQR, 16.8 to 37.8 weeks). Thirty-eight SAE occurred in 30 patients (15%), with a median time delay of 34 days (IQR, 14.75 to 60.5 days), including 10 patients with hematologic reactions, 9 with cutaneomucosal reactions, 6 with acute renal injuries, 4 with hypokalemia, and 4 with cholestatic hepatitis. The most frequently implicated antimicrobials were antistaphylococcal penicillins (ASP) (13 SAE/145 patients), fluoroquinolones (12 SAE/187 patients), glycopeptides (9 SAE/101 patients), and rifampin (7 SAE/107 patients). Kaplan-Meier curves and stepwise binary logistic regression analyses were used to determine the risk factors for the occurrence of antimicrobial-related SAE. Age (odds ratio [OR], 1.479 for 10-year increase; 95% confidence interval [CI], 1.116 to 1.960; P = 0.006) appeared to be the only independent risk factor for SAE. In patients receiving ASP or rifampin, daily dose (OR, 1.028; 95% CI, 1.006 to 1.051; P = 0.014) and obesity (OR, 8.991; 95% CI, 1.453 to 55.627; P = 0.018) were associated with the occurrence of SAE. The high rate of SAE and their determinants highlighted the importance of the management and follow-up of BJI, with particular attention to be paid to older persons, especially for ASP dosage, and to rifampin dose adjustment in obese patients.

Probable hepatic tuberculosis masquerading as Klatskin tumour in an immunocompetent patient.

A 55-year-old immunocompetent woman was presented with features of obstructive jaundice and a clinicoradiological picture suggestive of a hilar cholangiocarcinoma (Klatskin tumour). However, caseating granulomatous lesion associated with miliary nodules were revealed intraoperatively. The lesion responded to standard antituberculous therapy. This unusual presentation highlights the considerable diagnostic challenge in such case.

The effects of pomegranate on bacterial translocation in rats with obstructive jaundice.

BACKGROUND: Obstructive jaundice may promote bacterial overgrowth and altered intestinal barrier function, with resultant increased bacterial translocation. AIMS: This study aimed to evaluate potential effects of pomegranate on bacterial translocation after bile duct ligation in rats. MATERIALS AND METHODS: Wistar albino rats were randomized into four groups. Group 1 underwent sham operation; Group 2 underwent sham operation and simultaneous treatment with pomegranate; Group 3 underwent common bile duct ligation, and Group 4 underwent common bile duct ligation and simultaneous treatment with pomegranate. After 8 days, the samples of systemic blood, liver, spleen and mesenteric lymph nodes (MLNs) were obtained under sterile conditions for microbiological culture. The segments of the ileum were removed for histopathological examination. RESULTS: Bacterial translocation significantly decreased in Group 4 compared to Group 3 (p = 0.007). The bacterial counts (Colony forming unit: CFU/g) of Group 3 were significantly higher than those of Groups 1, 2 and 4 (p < 0.05). The mean ileal villus heights in the Groups 1, 2, 3 and 4 were 480.5±20.5 µm, 494.7±17.3 µm, 356.3±25.7 µm and 420.7±23.7 µm, respectively. The mean villus height in Group 4 was higher than that of Group 3 (p = 0.010). CONCLUSIONS: Pomegranate has significant protective effects on intestinal mucosa barrier in obstructive jaundice and reduces bacterial translocation.