Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis

Seo, Nieun,Kim, So Yeon,Lee, Seung Soo,Byun, Jae Ho,Kim, Jin Hee,Kim, Hyoung Jung,Lee, Moon-Gyu The Korean Society of Radiology 2016 KOREAN JOURNAL OF RADIOLOGY Vol.17 No.1

<P>Sclerosing cholangitis is a spectrum of chronic progressive cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts, which can be classified as primary and secondary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic progressive liver disease of unknown cause. On the other hand, secondary sclerosing cholangitis has identifiable causes that include immunoglobulin G4-related sclerosing disease, recurrent pyogenic cholangitis, ischemic cholangitis, acquired immunodeficiency syndrome-related cholangitis, and eosinophilic cholangitis. In this review, we suggest a systemic approach to the differential diagnosis of sclerosing cholangitis based on the clinical and laboratory findings, as well as the typical imaging features on computed tomography and magnetic resonance (MR) imaging with MR cholangiography. Familiarity with various etiologies of sclerosing cholangitis and awareness of their typical clinical and imaging findings are essential for an accurate diagnosis and appropriate management.</P>

Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis

서니은,김소연,이승수,변재호,김진희,김형중,이문규 대한영상의학회 2016 Korean Journal of Radiology Vol.17 No.1

Sclerosing cholangitis is a spectrum of chronic progressive cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts, which can be classified as primary and secondary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic progressive liver disease of unknown cause. On the other hand, secondary sclerosing cholangitis has identifiable causes that include immunoglobulin G4-related sclerosing disease, recurrent pyogenic cholangitis, ischemic cholangitis, acquired immunodeficiency syndrome-related cholangitis, and eosinophilic cholangitis. In this review, we suggest a systemic approach to the differential diagnosis of sclerosing cholangitis based on the clinical and laboratory findings, as well as the typical imaging features on computed tomography and magnetic resonance (MR) imaging with MR cholangiography. Familiarity with various etiologies of sclerosing cholangitis and awareness of their typical clinical and imaging findings are essential for an accurate diagnosis and appropriate management.

Association Between Extrahepatic Duct Diameter on Abdominal Computed Tomography and Severity Classified Using Tokyo Guidelines 2013 in Elderly Patients With Cholangitis

Hyeon Song Kim,Chang Min Lee,Byuk Sung Ko,Sung Hyuk Park,Woong Jung,Myung Chun Kim,고영관 대한노인병학회 2016 Annals of geriatric medicine and research Vol.20 No.4

Background: It is important to estimate the severity of early stage cholangitis in elderly patients to determine the most appropriate timing of biliary decompression. Abdominal computed tomography (CT) is the modality of choice for the diagnosis of cholangitis; however, studies evaluating the correlation between cholangitis severity and CT findings, specifically extrahepatic duct (EHD) diameter, are insufficient. Therefore, this study aimed to evaluate the relationship between EHD diameter and disease severity in elderly patients with cholangitis. Methods: A total of 155 patients over the age of 65 years, admitted to the Emergency Department, with a diagnosis of cholangitis from January 2010 to December 2015 were retrospectively analyzed. Using the Tokyo Guidelines 2013, patients were grouped into mild and moderate to severe cholangitis groups. We then analyzed the patient’s medical backgrounds, vital signs, and CT findings. To evaluate the significance of the CT findings in relation to cholangitis severity, a univariate analysis was performed within each group, using the collected variables. A multiple logistic regression analysis was performed using the variables with p<0.05. Results: On univariate analysis, EHD diameter (p<0.001) and combined cholecystitis (p=0.009) were found to be significant CT findings; EHD diameter (odds ratio [OR], 1.235; 95% confidence interval [CI], 1.115-1.368; p<0.001) and combined cholecystitis (OR, 2.666; 95% CI, 1.145-6.212; p=0.023) were also statistically significant after multiple logistic regression. Conclusion: In conclusion, increased EHD diameter was associated with disease severity in elderly patients with cholangitis. EHD diameter is easy to measure on CT and can be helpful in establishing an appropriate treatment plan.

The Prognostic Value of CD8+ and CD45RO+ T Cells Infiltration and Beclin1 Expression Levels for Early Postoperative Cholangitis of Biliary Atresia Patients after Kasai Operation

Hong Jiang,Pengfei Gao,Huadong Chen,Zhihai Zhong,Man Shu,Zhichong Zhang,Jinbiao She,Juncheng Liu 대한의학회 2018 Journal of Korean medical science Vol.33 No.30

Background: Postoperative cholangitis is a common but severe complication after Kasai portoenterostomy for biliary atresia (BA). This study aimed to identify its prognostic factors Methods: Two sets of liver paraffin-embedded tissue samples were collected from BA patients who received Kasai portoenterostomy (n = 25 and n = 31, respectively). Patients were divided into non-cholangitis and cholangitis groups. The infiltration of CD4+ , CD8+ , CD45RO+ , CD68+ cells and expression of Beclin1 were quantitatively evaluated in immunohistochemical analysis. Results: Cholangitis group had a significantly lower CD8+ T cell infiltration but a higher CD45RO+ cell infiltration, and a lower Beclin1 level than non-cholangitis group (all P < 0.01). Multivariate logistic regression analysis indicated that infiltration of CD8+ cells (odds ratio [OR], 0.112; 95% confidence interval [CI], 0.022–0.577) and CD45RO+ cells (OR, 3.88; 95% CI, 1.37–11.03), and Beclin1 level (OR, 0.088; 95% CI, 0.018–0.452) were independent influence factors for early postoperative cholangitis. Receiver operating characteristic (ROC) analysis showed that area under ROC curve (AUROC) values for CD8+ cells, CD45RO+ cells and Beclin1 were 0.857, 0.738 and 0.900, respectively. Conclusion: Our findings demonstrated the CD8+ cells, CD45RO+ cells and Beclin1 level possessed the prognostic value for early postoperative cholangitis following Kasai operation, which may be helpful to develop new prevention and treatment strategies for postoperative cholangitis.

Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis

Kristaps Atstupens,Haralds Plaudis,Vladimirs Fokins,Maksims Mukans,Guntars Pupelis 한국간담췌외과학회 2016 Annals of hepato-biliary-pancreatic surgery Vol.20 No.2

Backgrounds/Aims: Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. Methods: Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups. Results: Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. Conclusions: Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.

Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis

Kristaps Atstupens,Haralds Plaudis,Vladimirs Fokins,Maksims Mukans,Guntars Pupelis 한국간담췌외과학회 2016 한국간담췌외과학회지 Vol.20 No.2

Backgrounds/Aims: Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis. Methods: Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups. Results: Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate. Conclusions: Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.

응급진료센터에 내원한 급성 담관염 환자에서 혈액요소질소/알부민 비를 이용한 28일 사망률 예측의 유용성

강현솔,정성필,유제성,주영선,공태영,고동률,홍정화,박유석,정현수,박인철 대한응급의학회 2015 대한응급의학회지 Vol.26 No.6

Purpose: We evaluated the blood urea nitrogen (BUN)/albumin (B/A) ratio in patients with acute cholangitis to determine the prognostic significance of the B/A ratio as a marker of early mortality in critically ill patients with acute cholangitis. Methods: We retrospectively analyzed medical records in two emergency departments (ED) and screened eligible adult patients who were admitted to the ED with acute cholangitis. The B/A ratio was evaluated as the BUN value divided by albumin level on each hospital day. The clinical outcome was mortality after 28 days. Results: A total of 461 patients with acute cholangitis were included in this study. Multivariate Cox proportional hazard models showed that higher B/A ratio on ED admission (day 1) (Hazard Ratio (HR): 1.182; 95% Confidence Interval (CI): 1.076-1.298, p<0.001) and day 4 (HR: 1.192; 95% CI: 1.019-1.395, p=0.028) were independent risk factors for mortality at 28 days. Our study showed that the increased 28-day mortality was associated with a B/A ratio >6.83 on day 1 (HR: 4.065; 95% CI: 4.123-43.737, p<0.001) and a higher B/A ratio (>6.26) on day 4 (HR: 7.16; 95% CI: 1.412- 36.333, p=0.018) in patients with acute cholangitis. Conclusion: The ratio of BUN to albumin on ED admission is a promising prognostic marker of 28-day mortality in patients with acute cholangitis.

응급의료센터에서 시행된 급성담관염 환자의 컴퓨터단층촬영 소견: 패혈증 군과 비 패혈증 환자 군의 비교

김석균,이종석,최한성,홍훈표,고영관,권오영 대한응급의학회 2010 대한응급의학회지 Vol.21 No.4

Purpose: We undertook this study to evaluate the significance of differences in computed tomography (CT) findings between septic and non-septic acute cholangitis patients. Methods: One hundred seventy two patients were enrolled in our study. Inclusion criteria for patients were a final diagnosis of acute calculous cholangitis. Patients were divided into two groups: those who had sepsis and those that did not. The two patient groups were compared in order to investigate clinically important CT findings in acute cholangitis with and without sepsis. We also compared signs,symptoms, and laboratory findings between the groups. A p-value <0.05 was considered to be statistically significant. Results: Of the CT findings in acute cholangitis, the presence of intrahepatic duct dilatation (p<0.05), pancreatic duct dilatation (p<0.05), and pancreatitis (p<0.05) were more frequently found in the septic patient group. Septic patients showed fever (p<0.05) and chill (p<0.05) more often as presenting symptoms. Platelet count (p<0.05), segmented neutrophil portion (p<0.001), creatinine (p<0.05), and bicarbonate level (p<0.005) were significantly different in laboratory tests. Conclusion: Acute cholangitis patients with sepsis have more clinically important findings on CT, such as the presence of intrahepatic duct dilatation, pancreatic duct dilatation,and pancreatitis. Emergency physicians should focus on these findings and manage patients more urgently when these findings are present in acute cholangitis.

담관의 막힘이 없는 급성담관염의 원인과 영상분석

조정현,권희진,강명진,윤성국,조진한 대한영상의학회 2010 대한영상의학회지 Vol.62 No.6

Purpose: The aim of this study is to determine the causes of acute cholangitis without the biliary obstruction and radiological findings. Materials and Methods: This study was performed retrospectively. A total of 135 patients diagnosed with acute cholangitis in a clinical setting based on the review of the radiologic findings from an ultrasonogram (USG), computed tomogram (CT), or magnetic resonance images (MRI). Among them, patients with a biliary obstruction as a result of a stone, tumor, lymph node, stricture were excluded. A total of 31 patients had acute cholangitis without a definite biliary obstruction. We analyzed their causes and imaging features with the USG and CT image. Results: The causes of acute cholangitis without biliary obstruction included Clonorchis sinensis cholangitis in 15 cases (48%), post-operative swelling after gastrojejunostomy, pylorus preserved partial duodenectomy, and choledochojejunostomy in 7 cases (22.6%), recent spontaneous passage of a distal CBD stone in 3 cases (9.7%), compression effect by the large duodenal diverticulum in 2 cases (6.5%), and unknown causes in 4 cases (12.9%). Conclusion: Acute cholangitis may be associated without a distal biliary obstruction. USG, CT, or MR imaging can provide precise information as well as help to differentiate the causes of acute cholangitis. 목적: 담관의 막힘이 없이 발생한 급성담관염의 원인과 영상소견을 알아보고자 하였다. 대상과 방법: 최근 1년간 임상적 소견과 초음파를 시행하고 전산화단층촬영과 자기공명영상 중 1가지 이상을 촬영하여 급성담관염으로 진단된 환자 135명의 환자를 대상으로 후향적으로 분석하였다. 환자를 담도 막힘이 있는 경우와 없는 경우의 두 군으로 나누었으며 이중 결석, 종양, 림프선 비대, 협착 등의 담도 막힘이 있는 경우를 제외한 나머지 31명의 환자를 대상으로 하여 원인을 분류하고 영상의학적 검사 소견을 분석하였다. 결과: 담도 막힘이 없는 급성담관염이 발생한 31명의 환자 중 간디스토마로 진단된 경우가 15예, 위공장문합술 후 부종, 위유문보존 췌.십이지장 절제술, 총담관 공장문합술을 포함한 상복부 수술 후 발생한 경우가 7예, 총수담관 담석의 자연배설 직후가 3예, 십이지장 팽대부 주위게실이 2예였으며, 원인을 찾을 수 없었던 경우가 4예였다. 결론: 급성담관염의 일부는 원위부 담도의 막힘이 없이도 발생할 수 있다. 이러한 경우 전산화단층촬영술 혹은 자기공명영상과 초음파소견으로 그 원인을 추론할 수 있다.

부분 비장색전술로 부분관해된 특발성 문맥압항진증 1 예

김수영(Su Young Kim),김병호(Byung Ho Kim),이승훈(Seung Hoon Lee),오주형(Joo Hyeong Oh),이상목(Sang Mock Lee),김교영(Gyo Young Kim),김윤화(Youn Hwa Kim),이주희(Ju Hie Lee),동석호(Seok Ho Dong),김효종(Hyo Jong Kim),장영운(Young Woon ch 대한소화기학회 2001 대한소화기학회지 Vol.38 No.1

Background/Aims: Hepatolithiasis usually causes critical complications. Particularly, recurrent cholangitis is developed even after treatment. In this study, we aimed to find out the risk factors for recurrent cholangitis after management of hepatolithiasis, Methods: We reviewed the medical records of 196 patients with hepatolithiasis who had been diagnosed newly and treated at Seoul National University Hospital between January 1980 and August 2000. Then, the cumulative rate of cholangitis after treatment of hepatolithiasis and the possible risk factors for cholangitis through univariate and multivariate analysis were evaluated. Results: The cumulative rate of cholangitis of all patients was 9.6%/patient-year. Univariate analysis revealed that the presence of residual stone after treatment (p<0.0001), common bile duct stone before treatment (p=0.0066), stone recurrence after treatment (p=0.0014), and disruption of the sphincter of Oddi (p=0.0046) were significantly associated with recurrent cholangitis. By multivariate analysis using Cox model, the presence of residual stones, recurrence of stones, and the disruption of sphincter of Oddi were turned out to be the independent risk factors, but the presence of common bile duct stones was not. Conclusions: Complete removal of bile duct stone, prevention of recurrent stones, and preservation of the sphincter of Oddi can decrease the rate of cholangitis in patients with hepatolithiasis. (Korean J Gastroenterol 2001;38:42-47)