Cholangio‐venous reflux of biliary contents through paracellular pathways between hepatocytes in patients with acute cholangitis

Abstract

Background We re‐analyzed data on cholangio‐venous reflux from a clinical study conducted prospectively on 22 patients in 1974. Method Direct cholangiography was performed with indocyanine green (ICG) mixed into UrographinR under monitoring of intrabiliary pressure, and the participants were allocated to three groups according to whether ICG leakage into the blood, signs of infection, or both, were present. Results The intrabiliary pressure of six patients negative for both ICG leakage and signs of infection was approximately 19.5 (median, [range 18‐22]) cmH2O. In contrast, for the five patients positive for ICG leakage but negative for signs of infection, the intrabiliary pressure was higher (median 32.0 [range 27‐41) cmH2O]. The 11 patients positive for both ICG leakage and signs of infection had the highest intrabiliary pressure (median 48.0 [range 33‐77] cmH2O). Our analyses revealed that, as the intrabiliary pressure increased, the status of ICG leakage and signs of infection appeared in a stepwise fashion. Conclusion Our findings suggest that the tight junctions sealing the bile canaliculi deteriorated with increasing intrabiliary pressure, resulting in reflux of the biliary contents into the vascular system via paracellular pathways between hepatocytes.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone‐induced acute cholangitis and pancreatitis

“…However, if stone removal takes a long time for a patient with cholangitis, it has the potential to exacerbate the patient's condition, such as by increasing intraductal bile duct pressure, thereby promoting bacteremia. 49 If the stones are hard or there is a large number of stones, it is safer not to insist on singlesession stone removal. It remains controversial whether a drainage tube should be placed after single-session stone removal.…”

“…In cases with a low risk of bleeding without coagulopathy or the use of antithrombotic agents, single‐session stone removal is suggested for mild and moderate cholangitis in TG18. However, if stone removal takes a long time for a patient with cholangitis, it has the potential to exacerbate the patient's condition, such as by increasing intraductal bile duct pressure, thereby promoting bacteremia 49 . If the stones are hard or there is a large number of stones, it is safer not to insist on single‐session stone removal.…”

Risk factors of early adverse events associated with endoscopic ultrasound-guided hepaticogastrostomy using self-expandable metal stent

“…In the analyses of various factors related to AE and EUS-HGS, acute cholangitis was not observed in patients with a bile duct diameter less than 4 mm, although there were no statistically significant differences. However, two cases of bacteremia, presumably caused by similar mechanisms such as cholangiovenous and cholangiolymphatic reflux [17], were observed. Therefore, it is unlikely that bile ducts smaller than 4 mm are at a low risk for cholangitis.…”

Significant positive impact of duodenum‐preserving pancreatic head resection on the prevention of postoperative nonalcoholic fatty liver disease and acute cholangitis

“…The development of postoperative acute cholangitis after PD may be caused by hepaticojejunostomy, and one possible cause is the reflex of intestinal fluid and intestinal gas into the intrahepatic bile duct, resulting in increased intraductal pressure and bacteremia 12 . Anastomotic stenosis is also a major cause of cholangitis, and patients with a preoperative narrow bile duct diameter in benign disease are at high risk of recurrent cholangitis 13 .…”

“…The development of postoperative acute cholangitis after PD may be caused by hepaticojejunostomy, and one possible cause is the reflex of intestinal fluid and intestinal gas into the intrahepatic bile duct, resulting in increased intraductal pressure and bacteremia. 12 Anastomotic stenosis is also a major cause of cholangitis, and patients with a preoperative narrow bile duct diameter in benign disease are at high risk of recurrent cholangitis. 13 Therefore, patients with almost no jaundice, no bile duct dilatation, and low‐grade tumors, such as primitive neuroectodermal tumor, solid‐pseudopapillary neoplasm, or intraductal papillary mucinous neoplasm, are likely to have a high risk of postoperative cholangitis, and their postoperative QOL might be greatly impaired.…”