Introduction

Patients with symptomatic cholelithiasis can be stratified according to the 2019 European Society for Gastrointestinal Endoscopy (ESGE) guideline into low-, intermediate- and high-likelihood categories for the presence of choledocholithiasis. For the intermediate group, endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is recommended to assess whether an endoscopic retrograde cholangiopancreatography (ERCP) is necessary prior to cholecystectomy. The aim of the study is to investigate adherence to the guideline for diagnostic and treatment strategy for cholelithiasis in daily clinical practice.

Aims & Methods

Multicenter, retrospective cross-sectional observational study of the diagnostic pathway of patients with suspicion of choledocholithiasis between 2019 and 2021. Patients were stratified according to the ESGE guideline.

Results

A total of 305 patients were included in the analysis and stratified into low (17%), intermediate (40%) and high (43%) likelihood of choledocholithiasis. In these three categories, 182 (60%) patients underwent ERCP. Adherence to the ESGE guideline recommendation to perform additional imaging was 59.7% overall and was the highest in the intermediate group (83.6%) (p <0.001). In 195 patients who underwent additional imaging, 55 ERCPs (28.2%) could be avoided.

Conclusion

This study shows that stratification according to the ESGE guidelines is useful to reduce the number of unnecessary diagnostic imaging procedures and ERCPs in patients with a suspicion of choledocholithiasis. It can be worthwhile to perform EUS prior the ERCP in the same session.

Disclosure

Mike J.P. de Jong, Megan M.L. Engels, Christina J. Sperna Weiland, Tanya M. Bisseling, Robin Krol and Foke van Delft have no conflict of interest or financial ties to disclose. Jeanin E. van Hooft reports lecture fees from Cook Medical, dr. Falk Pharma, Boston Scientific, AbbVie, and consultancy fees from Olympus. Erwin M. van Geenen reports research grants from Olympus, Boston Scientific, and MTW Endoskopie. Peter D. Siersema reports research grants from Pentax and Fujifilm. All outside the submitted work.

Introduction

The "Antimicrobial Resistance in Acute Cholangitis" (ARISE) study is a prospective investigation focused on the antimicrobial resistance patterns in patients with acute cholangitis undergoing ERCP. Conducted across multiple tertiary gastroenterology centers in Romania, this study aims to identify, analyze, and mitigate the challenges posed by multidrug-resistant (MDR) organisms in managing acute cholangitis.

Aims & Methods

Data collected included microbial cultures from bile samples, patient demographics, clinical outcomes, and antibiotic resistance profiles. From the study's onset in January 2024, 138 eligible patients were identified as having positive bile cultures. Among these patients, the predominant symptoms included abdominal pain (82.6%), jaundice (71%), and fever or shaking chills (36.2%). The diagnosis of acute cholangitis was established using TG18 criteria.

Results

Bile cultures were positive in 71.0% of cases. The most frequently isolated bacteria were Escherichia coli, found in 23.2% of positive cultures, followed closely by Enterococcus spp., present in 22.5% of cases. Klebsiella pneumoniae was also notably prevalent, identified in 7.2% of the bile samples. Ciprofloxacin showed the highest resistance rate among the tested antibiotics, with a resistance rate of 23.9%. Ampicillin and gentamicin displayed significant resistance rates at 10.9% and 18.8%, respectively. Piperacillin/tazobactam and trimethoprim/sulfamethoxazole each showed a resistance rate of 15.2%. The study's data on tigecycline and linezolid showed lower resistance rates, with tigecycline maintaining a sensitivity rate of 20.3% and linezolid at 19.6% in cultures where testing was applicable. In comparison, their resistance rates were only 0.7% for each. Multidrug resistance was identified in a significant fraction of isolates, with 15.2% of samples. A concerning finding was the presence of MDR strains of Escherichia coli, which exhibited resistance rates to ampicillin (21.0% sensitivity, 10.9% resistance) and amoxicillin/clavulanic acid (17.4% sensitivity, 14.5% resistance).

Conclusion

We observed a concerning prevalence of MDR organisms in acute cholangitis cases, particularly against antibiotics such as ampicillin, gentamicin, and ciprofloxacin, with a high incidence of MDR Escherichia coli strains.

Clinical Case Summary

We describe the case of a 38-year-old patient referred to a general surgery consultation due to gastric polypoid lesions, suspected of neoplasia. Since the biopsies were negative for adenocarcinoma/dysplasia, another esophagogastroduodenoscopy was performed which showed several erythematous polypoid areas with a villous appearance, extensive and scattered, mainly in the gastric body and cardia. Only hyperplastic polyps were identified, without dysplasia. The patient underwent a colonoscopy which identified a pedunculated polyp with 50mm in the colon which was removed (serrated without dysplasia) and around 10 polyps measuring 5-10mm spread throughout the colon (two removed and identified as hyperplastic).
The mother underwent total gastrectomy for gastric polyposis associated with hypoalbuminemia and right hemicolectomy for cecum polyposis in 2004 (without access to the histology of the surgical specimens). During follow-up, colonoscopies were performed and the polyps removed were identified as hyperplastic.
The patient underwent a genetic study with a polyposis panel that detected a deletion of approximately 301.5kb that involved the entire SMAD4 gene, classified as pathogenic. Pathogenic variants in the SMAD4 gene are associated with Juvenile Polyposis syndrome (JPS), Myhre syndrome, and Juvenile Polyposis/Hereditary Hemorrhagic Telangiectasia. Given the clinical context, in the genetic consultation, it was assumed that it was Juvenile Polyposis syndrome, with autosomal dominant transmission. His mother will be tested for this mutation.

JPS is characterized by histologically characteristic hamartomatous polyps of the gastrointestinal tract, specifically in the stomach, small intestine, and colorectum. Patients with JPS associated with SMAD4 mutations are more likely to develop gastric polyps and have a higher risk of gastric cancer. To the authors' knowledge, this phenotype of hyperplastic/serrated polyps has not been described in patients with this pathology.