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Introduction

Acute bacterial cholangitis is a medical emergency, requiring prompt antibiotic administration and biliary decompression. Normally, bile is devoid of microbes. Obstruction
of the biliary system leads to bile stagnation, which predisposes to bacterial proliferation. Bacteria enter the bile duct from duodenum. Also, the increased bile duct pressure in the
obstructed biliary system leads to systemic dissemination of bacteria via cholangio-venous reflux leading to septicemia. Indiscriminate and widespread use of antibiotics over the years has altered the antibiotic sensitivity pattern of micro-organisms and the emergence of multidrug resistant bacteria pose a therapeutic challenge which needs further study.

Aims & Methods

We aimed to analyze the clinico-microbiological profile and outcomes of patients with acute bacterial cholangitis, who underwent endoscopic retrograde cholangiopancreatgraphy (ERCP) at a tertiary care hospital. Data on consecutive patients (n=116) with acute cholangitis who underwent ERCP, from January 2019 to August 2020, was retrospectively extracted. The demographic, clinical, etiological and biochemical profile was recorded. Also, bile culture reports, and antibiotic sensitivity pattern of organisms was recorded. Diagnosis of cholangitis was based on presence of fever and/or leukocytosis, in patients with biliary obstruction (cholestatic liver function tests, biliary dilatation on imaging). Organ failure was present if patients had altered sensorium, hypotension (systolic blood pressure <90 mm Hg), renal failure (serum creatinine >1.5 mg/dL), hypoxia (blood oxygen saturation <90%).

Results

The mean age of our study cohort was 47.56 +/- 13.58 years and 64.7% were females. Patients presented with abdominal pain (89.6%), jaundice (84.4%) and fever (56.8%) with 41.4% patients exhibiting Charcot’s triad and 1 having Reynolds’ pentad.
30 (25.8%) patients had organ failure with renal failure being the most common. 5 patients had multiple organ failure, all of which died during hospitalization. 60.3% patients had a benign cause of biliary obstruction; choledocholithiasis was the most common benign cause. Other benign causes included post cholecystectomy bile duct stricture, chronic pancreatitis, portal biliopathy. The most common malignant cause was carcinoma gall bladder (43.5%) followed by peri-ampullary carcinoma (30.4%), carcinoma head of pancreas (13%).
Positive bile culture was seen in 95 (81.9%) patients; of which 17 (17.9%) had polymicrobial growth in bile. 92.9% organisms were gram negative bacteria (GNB). Escherichia coli (45.13%) was the most common GNB followed by Pseudomonas (29.2%). 8 patients had gram positive organisms on culture (Enterococcus, 7.1%). Most common Multi-drug resistant organisms isolated were carbapenem-resistant Enterobacteriaceae. Escherichia coli and Klebsiella were most sensitive to amikacin, netilmicin and tigecycline. Pseudomonas had greatest sensitivity to amikacin, netilmicin and colistin.
80 (69%) patients were naïve, whereas the remaining 36 patients had previously undergone ERCP. 10.3 % patients died during hospital stay. Median duration of hospital stay was 6 (3-60) days.
Old age, lower serum albumin, higher blood urea and serum creatinine, septic shock and malignant etiology of biliary obstruction were associated with mortality on univariate analysis. On multivariate analysis, low serum albumin and septic shock were associated with higher in-hospital mortality.

Conclusion

Indiscriminate antibiotic use has resulted in increasing prevalence of multi-drug resistant organisms, with emergence of carbapenem resistant organisms posing a major therapeutic challenge.

CLINICAL PROFILE, MICROBIOLOGICAL SPECTRUM IN BILE AND PATIENT OUTCOMES IN CASES OF ACUTE BACTERIAL CHOLANGITIS

Alok Kumar Singh 1, Kartik Mehta 2, Aarushi Ahuja 2, Sanjeev Sachdeva 1, Gaurav Padia 1, Ashok Dalal 1, Ajay Kumar 1, Siddharth Srivastava 1, Ujjwal Sonika 1, Brajesh Chander Sharma 1

1 GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India

2 Maulana Azad Medical College, New Delhi, India

Conference

UEG Week Vienna 2024

Topics

Hepatobiliary

Submission format

Abstract

Session

BILIARY (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Post-pancreatectomy steatosis hepatis

Karen Geboes 1

1 Ghent University Hospital, St-Amandaberg (Gent), Belgium

Event

UEG Week Berlin 2025

Topics

Hepatobiliary Mechanisms & Personalised Medicine

Session

Therapy update: MASH and metabolic disorders

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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The usefulness of target trial emulations to enhance the field of Gastroenterology

Louise Emilsson 1

1 County Council of Värmland, Värmlands, Sweden

Event

UEG Week Berlin 2025

Topics

Mechanisms & Personalised Medicine Standards & Guidelines

Session

The art of making clinical research precise: Options for study design

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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The endoscopy nurse's guide to the GI galaxy

Anastasia Tsalouka 1

1 University General Hospital Attikon, Athens, Greece

Event

UEG Week Berlin 2025

Topics

Nurses

Session

ESGENA: Opening Session

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction

Endoscopic submucosal dissection has become the preferred technique for managing large colonic lesions or those suspected of superficial tumor invasion. Macronodular lesions may present with a muscular retraction sign (MRS), which is associated with reduced curative resection rates due to lower R0 resection rates and increased rates of deep submucosal invasion. A few data are available about how to differentiate fibrosis and cancer and about technical and oncological outcomes of ESD in this situation.

Aims & Methods

We conducted a prospective study to evaluate the prevalence of the muscular retraction sign and its clinical outcomes in patients with colorectal macronodular lesions. This analysis utilized data from a large prospective French colorectal ESD cohort (FECCo).

Results

A total of 1,238 macronodular lesions were treated, of which 254 (20.5%) exhibited a muscular retraction sign. The prevalence of MRS increased with the size of the largest macronodule, reaching up to 50% for nodules larger than 40 mm. Enbloc, R0 and curative resection rates were significantly lower in the MRS+ group (82.68% vs 97.86%, 70.97% vs 89.76% and 56.31% vs 83.52%, p<0.001 respectively). MRS+ lesions were more frequently associated with at least submucosal cancer (30.32% vs 9.65%, p<0.001). Regardless of MRS, the presence of a nodule larger than 4cm is associated with a decrease in enbloc resection rates, particularly in the colon, as well as reductions in R0 resection rates and curative resection rates in comparison with nodules smaller than 4cm. The curative resection rate for lesions with ≥T1 cancer and presenting with MRS was 1.5% (p<0.001).
In multivariate analysis, protruding lesions (OR = 1.91 [1.19–3.06], p = 0.007) and nodules larger than 20mm (OR = 2.48 [1.74–3.52], p<0.001) or 40mm (OR 5.98 [3.55-10.08], p<0.001) were identified as risk factors for MRS. The size of the nodule did not increase the risk of submucosal cancer, unlike sigmoid location (OR 2.66 [1.15-6.17] p=0.022) and nodules classified as JNET 3 (OR 6.53 [2.07-20.57], p=0.001).

Conclusion

The prevalence of MRS is 20.5% in cases of macronodular lesions, a rate that increases significantly with the size of the macronodule. MRS negatively impacts the outcomes of ESD in terms of enbloc, R0 and curative resections. ESD should be reconsidered in cases of large macronodular colonic lesions, especially for sigmoid locations or in the presence of JNET 3 vascular pattern anomalies. For rectal large macronodular lesions, ESD should be proposed in expert centers with the option, if necessary, of intermuscular dissection to optimize the R0 resection rate and thereby improve the chances of proposing an organ-preservation strategy.