Treatment of choice for choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver cirrhosis

Chijiiwa, Kazuo; Kozaki, Naoto; Naito, Tokio; Kameoka, Nobuhisa; Tanaka, Masao

doi:10.1016/s0002-9610(99)80303-1

Cited by 55 publications

(40 citation statements)

References 14 publications

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“…25 In our previous study, LPS-induced cholangitis in the jaundiced rats is significantly associated with higher grade of liver necrosis and mortality rate. 24 Endotoxin (LPS) is a potent inducer of inflammatory cytokines, including IL-6, and is known to induce hepcidin expression.…”

Section: Cholestasis Attenuates the Endotoxin-induced Hepcidin Expresmentioning

confidence: 90%

Cholestasis downregulate hepcidin expression through inhibiting IL-6-induced phosphorylation of signal transducer and activator of transcription 3 signaling

Huang

Chuang

Yang

et al. 2009

Laboratory Investigation

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Hepcidin is downregulated during progressive cholestasis in biliary atresia, but the mechanism is unknown. To verify whether downregulation of hepcidin is specific to cholestasis irrespective of the patient's age, we first analyzed liver hepcidin mRNA and protein expression in adults with primary biliary cirrhosis (PBC) (n ¼ 4), non-cholestatic cirrhosis (n ¼ 19) and in controls (n ¼ 9). We evaluated the tyrosine phosphorylation of signal transducer and activator of transcription 3 (pSTAT3) expressions in the liver sections. A rat model of cholestasis by ligation of the extrahepatic bile duct (BDL) was created, and lipopolysaccharide (LPS)-induced cholangitis in cholestatic rats 2 weeks after BDL was also established to study the modulation of hepcidin by interleukin-6 (IL-6) and STAT3 signaling pathway in these models, using real-time quantitative reverse transcription-PCR, immunohistochemistry, western blotting and enzyme-linked immunosorbent assay (ELISA). An in vitro study of the effect of bile acids on hepcidin expression was carried out to re-confirm the in vivo findings. There was significantly lower hepcidin mRNA and pSTAT3 protein expression in cholestatic cirrhosis compared with non-cholestatic cirrhosis in adults. BDL caused significant decrease in hepcidin and gp130 mRNA expression compared with sham-operated group and normal control. Furthermore, there was significantly lower pSTAT3 protein expression and nuclear translocation in the cholestatic liver from the patients and the BDL rats, which was comparable to lower liver hepcidin mRNA and plasma hepcidin expression. Furthermore, BDL for 2 weeks attenuated the upregulation of hepcidin expression induced by LPS. Hydrophobic bile acid glycochenodeoxycholate inhibited IL-6-induced pSTAT3 expression in primary hepatocytes and resulted in the downregulation of hepcidin mRNA expression. In conclusion, the study shows that cholestasis or its important component-hydrophobic bile acids-can downregulate hepcidin expression through inhibiting IL-6-induced STAT3 phosphorylation and pSTAT3 protein nuclear translocation.

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Section: Cholestasis Attenuates the Endotoxin-induced Hepcidin Expresmentioning

confidence: 90%

Cholestasis downregulate hepcidin expression through inhibiting IL-6-induced phosphorylation of signal transducer and activator of transcription 3 signaling

Huang

Chuang

Yang

et al. 2009

Laboratory Investigation

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“…Burdiles et al [8]reported that this diagnosis increased eight times the risk of death in patients with choledocholithiasis, although this was not quantified by multivariate analysis. Similarly, Chijiiwa et al [22]reported that endoscopic sphincterotomy was associated with lower mortality rates than surgery in patients with choledocholithiasis associated with acute obstructive suppurative cholangitis and liver cirrhosis, in a retrospective study which included 362 patients with choledocholithiasis. The results of this analysis were not statistically different because of the small sample size.…”

Section: Discussionmentioning

confidence: 99%

“…The latter has the greatest influence on mortality rate, since it increases eight times the probability of postoperative death. Thus, an adequate perioperative cardiovascular management may be important in order to improve surgical outcome; appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality, and, finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients, in order to drain the CBD and decrease the risk of biliary sepsis [22, 23, 25]. …”

Section: Discussionmentioning

confidence: 99%

Open Biliary Tract Surgery: Multivariate Analysis of Factors Affecting Mortality

Larraz-Mora

Mayol²,

Martinez-Sarmiento³

et al. 1999

Dig Surg

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Background/Aim: The overall mortality rate in patients undergoing supraduodenal choledochotomy for benign biliary tract disease is around 3%. The aim of this study is to identify and quantify factors affecting the mortality in a group of patients undergoing open common bile duct exploration for benign biliary disease. Methods: Patients (n = 158) who underwent common bile duct exploration during a 5-year period in a teaching hospital were retrospectively reviewed. Results: Univariate and multivariate statistical analyses were performed. The former identified four statistically significant variables: age (p < 0.001), acute cholangitis on admission (p < 0.001), heart disease (p < 0.05), and a dilated common bile duct on preoperative ultrasound scan (p < 0.05). Multivariate analysis identified three variables which independently increased operative mortality: age (p = 0.05), heart disease (p = 0.03), and cholangitis (p = 0.008). The latter was associated with the greatest operative mortality, since it increased almost eight times the risk to die after surgical intervention. Conclusion: We conclude that an adequate perioperative cardiovascular management may be important in order to improve surgical outcome. Appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality. Finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients in order to drain the common bile duct preoperatively and to decrease the risk of unresponsive biliary sepsis.

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“…[11][12][13][14][15][16] However, endoscopic facilitation of biliary drainage may be life saving in patients with acute suppurative cholangitis and biliary obstruction. [17][18][19][20][21][22][23] However, patients with HCC have an increased risk of bleeding due to liver dysfunction, and a mortality of up to 50% for surgery and up to 22% for endoscopic sphincterotomy (EST) has been reported for patients with cirrhosis and coagulopathy. [19][20][21][22] A potentially safer alternative to EST is endoscopic papillary balloon dilatation (EPBD) in which complications such as severe bleeding are rare, even in patients with advanced cirrhosis.…”

mentioning

confidence: 99%

“…[17][18][19][20][21][22][23] However, patients with HCC have an increased risk of bleeding due to liver dysfunction, and a mortality of up to 50% for surgery and up to 22% for endoscopic sphincterotomy (EST) has been reported for patients with cirrhosis and coagulopathy. [19][20][21][22] A potentially safer alternative to EST is endoscopic papillary balloon dilatation (EPBD) in which complications such as severe bleeding are rare, even in patients with advanced cirrhosis. [24][25][26][27] Thus we adopted EPBD as the firstline treatment for extrahepatic biliary obstruction occurring in patients with HCC.…”

mentioning

confidence: 99%

Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation

Sasahira

Tada²,

Yoshida³

et al. 2005

Gut

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Background and aims: Percutaneous tumour ablation (PTA), such as ethanol injection and radiofrequency ablation, is now recognised as a primary treatment for hepatocellular carcinoma (HCC). Although PTA is a relatively safe procedure, it can cause biliary obstruction as a rare complication. As patients with cirrhosis undergoing surgery or endoscopic retrograde cholangiopancreatography/sphincterotomy have a high mortality rate from bleeding, we adopted the use of endoscopic papillary balloon dilatation (EPBD) in these patients and now report the results. We retrospectively analysed the incidence of biliary obstruction after PTA and the efficacy of treatment with EPBD. Patients and methods: A total of 1043 patients with HCC were treated by PTA, of whom 538 were treated with transarterial embolisation with up to eight years of follow up.Results: There were 17 (1.6%) cases of hilar obstruction due to tumour progression and 35 (3.4%) cases of extrahepatic obstruction. Apart from the expected causes of biliary obstruction (haemobilia n = 11, gallstones n = 11, and three miscellaneous causes), we found that 10 patients had obstruction due to biliary casts. This is the first description of biliary casts after percutaneous tumour ablation therapy. Extrahepatic biliary obstruction by procedure related haemobilia occurred within three days of PTA while other causes occurred between 0 and 17 (average 4.9) months. Biliary casts occurred more frequently after ethanol injection than after radiofrequency ablation. EPBD successfully dissipated biliary obstruction in 33 of 35 cases, while two died due to hepatic failure despite successful drainage. Conclusions: Extrahepatic biliary obstruction is an uncommon complication after PTA for HCC, and can be safely and effectively treated with EPBD, despite impaired liver function.

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Treatment of choice for choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver cirrhosis

Cited by 55 publications

References 14 publications

Cholestasis downregulate hepcidin expression through inhibiting IL-6-induced phosphorylation of signal transducer and activator of transcription 3 signaling

Cholestasis downregulate hepcidin expression through inhibiting IL-6-induced phosphorylation of signal transducer and activator of transcription 3 signaling

Open Biliary Tract Surgery: Multivariate Analysis of Factors Affecting Mortality

Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation

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