sign in sign up
<<
Home , Ascending cholangitis, Cholestasis

FRONTIERS IN , SERIES #47 FRONTIERS IN ENDOSCOPY, SERIES #47

Douglas G. Adler MD, FACG, AGAF, FASGE, Series Editor Current Management of

Dan McEntire Douglas G. Adler

Ascending cholangitis is an infectious syndrome of the biliary tree that can pose significant morbidity to affected patients if not recognized and treated appropriately. Accurate diagnosis and assessment of disease severity is essential to guide selection of antimicrobials, timing of biliary decompression, and selection of a decompression technique. This article reviews the current literature related to ascending cholangitis management, in conjunction with current international guidelines.

INTRODUCTION scending cholangitis (AC) is an infection of polymicrobial.2 The most frequently isolated Gram- the . The normal biliary tree is negative organisms are E. coli and K. pneumoniae, near-sterile secondary to constant drainage, with species being the most common A 3,4 bacteriostatic salts, and mucosal immune Gram-positive organism. Anaerobes, primarily mechanisms. Biliary obstruction disrupts these and , are relatively processes and causes elevated intraductal pressure infrequently isolated.3,4 with increased permeability, which Accurate diagnosis and assessment of permits endotoxin and bacterial translocation severity are fundamental to guide appropriate into lymphatic and portosystemic circulation.1 therapy. In additional to clinical support and Biliary obstruction is most frequently caused resuscitation, administration and biliary by biliary stones, though there are many causes decompression represent the central components including mass effect of malignancy, benign and of AC management. This article presents current malignant strictures, parasites (e.g., Ascaris), and data pertinent to these areas. iatrogenic causes (e.g., biliary stenting, surgery).1 (Figures 1 and 2) Diagnosis of Ascending Cholangitis The organisms implicated in AC originate The classic clinical characteristics of AC are , from enteric flora, and cultures are usually right-upper-quadrant (RUQ) , and (Charcot’s triad). More severe cases may Dan McEntire MD, Douglas G. Adler MD, University present with and altered mental status of Utah School of Medicine, (Reynold’s pentad). However, because few cases and , Salt Lake City, UT present with all of these features, standardized

28 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 Current Management of Ascending Cholangitis FRONTIERS IN ENDOSCOPY, SERIES #47 FRONTIERS IN ENDOSCOPY, SERIES #47

criteria were recently developed.5,6 dysfunction. Organ dysfunction is defined as the The current Tokyo Guidelines 2018 (TG18) presence of cardiovascular dysfunction requiring diagnostic criteria for AC are based on evidence intravenous dopamine >5µg/kg/min or any of systemic , , and dose of norepinephrine, neurologic dysfunction biliary obstruction. The presence of systemic (i.e., disturbance of consciousness), respiratory

inflammation is defined as fever >38°C, shaking dysfunction (PaO2/FiO2 <300), renal dysfunction chills, leukocyte count <4,000/µL or >10,000/µL, (oliguria or serum creatinine >2mg/dL), or C-reactive protein (CRP) ≥1 mg/dL. Cholestasis hepatic dysfunction (INR >1.5), or hematologic is defined as clinical jaundice, total dysfunction ( count <100,000/µL). Grade ≥2 mg/dL, or alkaline phosphatase, aspartate II (moderate) cholangitis is defined by the presence aminotransferase, alanine aminotransferase, or of high fever (>39°C), leukocyte count <4,000/ gamma-glutamyltransferase >1.5 times the upper µL or >12,000/µL, advanced age (>75 years), or limit of normal. The presence of biliary dilatation, hypoalbuminemia (<70% lower limit of normal). or evidence of the etiology (e.g., stone, stricture), Grade I (mild) cholangitis lacks the aforementioned indicates obstruction. A definitive diagnosis is criteria. A large study that stratified patients by made when at least one criterion is met in each severity grade found 5.1%, 2.6%, and 1.2% 30- of the three categories. A suspected diagnosis is day mortality in patients with Grade III, II, and I made when one criterion is met in the systemic disease, respectively.7 inflammation category, plus one item in either the cholestasis or imaging categories. One study found that the diagnostic criteria successfully identified Initiation of antibiotics should occur within one 90% (73.1% definitive, 16.9% suspected) of cases.7 hour in cases of , or within six hours for The remaining undiagnosed 10% were mild cases all other cases.4,8 Prescribing adequate empiric that lacked systemic inflammation. This suggests coverage is becoming increasingly difficult due reasonable performance of criteria, especially for to antibiotic resistance patterns.2,9 Appropriate moderate to severe disease. selection of empiric coverage is also made with Imaging is necessary to make a definitive consideration given to comorbidity, allergy, or diagnosis of cholangitis (though clinical suspicion other factors. may be high in known cases of preexisting General recommendations for empiric pancreaticobiliary disease). Abdominal ultrasound coverage include intravenous treatment with a (US) is the suggested first step due to its wide third-generation cephalosporin or a availability, noninvasive nature, and low cost. US derivative/beta-lactamase inhibitor combination.4 is well suited to visualize the proximal common TG18 and the Surgical Infection Society/Infectious bile duct (CBD) and , Disease Society of America (SIS/IDSA) guidelines but visualization of the distal CBD is typically recommend to consult local antibiograms and limited. Computed tomography (CT) and administer alternative medications if community magnetic resonance imaging/magnetic resonance pathogen resistance exceeds 10-20%.4,10 cholangiopancreatography (MRI/MRCP) can be Ampicillin-sulbactam and fluoroquinolones are not performed. MRI/MRCP is favored given the high- recommended for empiric use due to widespread resolution imaging of the that E. coli resistance, but are frequently used in is possible. Invasive endoscopic or percutaneous clinical practice.2,4,9,10 Antipseudomonal agents imaging options, discussed below, can be both can be reserved for severe cases and healthcare- diagnostic and therapeutic. associated infection.3,4 Coverage of Enterococcus species with vancomycin is recommended in Severity Grading of Ascending Cholangitis severe or healthcare-associated disease, or in TG18 includes a severity grading system that immunocompromised patients.4,10 Anaerobic has prognostic value and may help to guide coverage with is recommended in appropriate intervention timing.5 Grade III (severe) patients with a surgical history of biliary enteric cholangitis is manifested by evidence of organ (continued on page 34) PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 29 Current Management of Ascending Cholangitis FRONTIERSNUTRITION ISSUES IN ENDOSCOPY, IN GASTROENTEROLOGY, SERIES #47 SERIES #174 (continued from page 29) Figure 1. Ascending Cholangitis Treated via ERCP

Figure 1a. Ampulla with purulent material visible at orifice Figure 1b. Cannulation of the bile duct with a sphincterotome

Figure 1c. After cannulation, copious starts to drain Figure 1d. After sphincterotomy a large stone is extracted spontaneously from the duct with a balloon catheter.

Figure 1e. A biliary is placed to further promote Figure 2. Placement of a metal stent via ERCP in a patient drainage of purulent contents. This stent was removed 2 with pancreatic who developed cholangitis. Note weeks later. purulent drainage. (continued on page 36)

34 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 Current Management of Ascending Cholangitis FRONTIERSNUTRITION ISSUES IN ENDOSCOPY, IN GASTROENTEROLOGY, SERIES #47 SERIES #174 FRONTIERS IN ENDOSCOPY, SERIES #47

(continued from page 34) Endoscopic Biliary Drainage or for general prophylaxis.4,10 This is ERCP biliary decompression by direct cannulation due to a relative scarcity of anaerobe isolation in of the major duodenal papilla is the gold standard AC, and reports that anaerobic coverage for other for acute cholangitis.25,26 This is due to high success indications does not improve outcomes.2,3,11,12,13 rates, minimally invasive nature, and fewer adverse Antibiotic treatment can be adjusted based events compared to percutaneous or surgical on patient response and pathogen susceptibility procedures.26,27,28,29 Disadvantages, however, include data. TG18 and SIS/IDSA guidelines recommend need for sedation.30 Endoscopic duct clearance a total of 4-7 days of therapy after source control by sphincterotomy, balloon extraction, and/or is obtained, obstruction removed, and assuming endoscopic stenting for strictures is performed absence of local complications (e.g., as needed. Patients in whom stone extraction abscess).4,10 In the presence of Gram-positive cannot be performed can simply undergo stent bacteremia, 2 weeks of therapy is recommended.4 placement. An additional adjunctive technique is direct cholangioscopy with lithotripsy. Nasobiliary Timing of Biliary Decompression drains are rarely used in modern practice.26,27,31 Several studies, mostly related to ERCP, have Balloon-assisted enteroscopy ERCP (BE-ERCP) assessed clinical outcomes in AC patients with is recommended in cases of altered postoperative regards to time-to-intervention but a clear consensus anatomy.25 has not been well defined. Based on findings biliary drainage of improved mortality in patients with Grade II (EUS-BD) is a relatively new and developing (moderate) disease that received biliary drainage technique, though current data are largely related within 48 hours, TG18 generally recommends to obstructive jaundice generally, and not specific decompression within 48 hours in patients.5,7 In to cholangitis. Several studies indicate that EUS- practice, however, sometimes patients are too BD, in the hands of experienced endoscopists, is unstable to undergo a drainage procedure and an effective alternative after failed ERCP and may require more time before biliary decompression. outperform percutaneous drainage.32,33,34,35,36,37,38 The recommendation for 48 hours as a general EUS-BD may also represent a feasible approach in cutoff is supported by investigators who found patients with surgically altered anatomy.39 Research worse outcomes (persistent organ failure, longer into the optimal tools and techniques to perform hospitalization, relapse, or mortality) in patients EUS-BD is ongoing. with further delayed decompression.14, 15, 16, 17, 18 In contrast, other accounts favor decompression Percutaneous Biliary Drainage within 24 hours, mostly on the basis of shorter Percutaneous techniques include percutaneous hospitalization.16,17,19,20,21 A recent study describes transhepatic biliary drainage (PTBD) and outpatient management of AC after endoscopic percutaneous cholecystostomy (PC). PTBD drainage, suggesting that early intervention in mild is currently the recommended alternative to to moderate disease can prevent hospitalization traditional ERCP drainage and may be required altogether.22 Patients with septic or critical when endoscopy is unavailable or contraindicated illness appear to warrant early decompression (e.g., unusual anatomy) or after failed ERCP.25 after appropriate resuscitation, with significantly PTBD usually involves local anesthesia, puncture improved mortality reported when decompressed of an intrahepatic duct with a fine needle under before 12 or 24 hours, respectively.23, 24 US or fluoroscopy, and placement of a drain. Successful needle placement requires ample intrahepatic ductal dilatation.40 PTBD is second- Biliary Drainage Techniques line to ERCP due to invasiveness, common Biliary drainage is recommended for all cases requirement for additional procedures, and higher of AC, irrespective of severity.25 Techniques for rate of adverse events.25,29,37 PTBD is primarily biliary decompression are broadly categorized into used to provide biliary drainage, whereas stone endoscopic, percutaneous, and surgical. (continued on page 43)

36 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 Current Management of Ascending Cholangitis FRONTIERSNUTRITION ISSUES IN ENDOSCOPY, IN GASTROENTEROLOGY, SERIES #47 SERIES #174 FRONTIERS IN ENDOSCOPY, SERIES #47

(continued from page 36 ) Chen MF, Jan YY, Ker CG, Wang HP, Wada K, Yamaue removal is much less commonly performed via this H, Miyazaki M, Yamamoto M. Updated comprehensive epidemiology, microbiology, and outcomes among patients route. Patients with stones and AC often require with acute cholangitis. J Hepatobiliary Pancreat Sci. 2017 ERCP at a later time to remove the stones from Jun;24(6):310-318. doi: 10.1002/jhbp.452. Epub 2017 May the biliary tree, usually via sphincterotomy and 26. PubMed PMID: 28371094. balloon/basket extraction. PC, though rarely used 4. Gomi H, Solomkin JS, Schlossberg D, Okamoto K, Takada T, Strasberg SM, Ukai T, Endo I, Iwashita Y, Hibi T, Pitt HA, for this indication, can be a useful alternative to Matsunaga N, Takamori Y, Umezawa A, Asai K, Suzuki K, PTBD, especially if intrahepatic duct dilation is Han HS, Hwang TL, Mori Y, Yoon YS, Huang WS, Belli insufficient to allow a successful transhepatic G, Dervenis C, Yokoe M, Kiriyama S, Itoi T, Jagannath P, 41,42 Garden OJ, Miura F, de Santibañes E, Shikata S, Noguchi approach. Y, Wada K, Honda G, Supe AN, Yoshida M, Mayumi T, Gouma DJ, Deziel DJ, Liau KH, Chen MF, Liu KH, Su Surgical Biliary Drainage CH, Chan ACW, Yoon DS, Choi IS, Jonas E, Chen XP, Fan ST, Ker CG, Giménez ME, Kitano S, Inomata M, Mukai Surgical drainage of the biliary ducts is generally S, Higuchi R, Hirata K, Inui K, Sumiyama Y, Yamamoto thought of as the last option after unsuccessful M. Tokyo Guidelines 2018: antimicrobial therapy for acute endoscopic or percutaneous intervention.25 This is cholangitis and . J Hepatobiliary Pancreat Sci. primarily due to high success rates of less invasive 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518. Epub 2018 Jan 9. PubMed PMID: 29090866. techniques and observations of higher mortality 5. Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida compared to other less invasive methods.1,25,28 M, Mayumi T, Strasberg S, Pitt HA, Gadacz TR, Büchler MW, Belghiti J, de Santibanes E, Gouma DJ, Neuhaus H, Dervenis C, Fan ST, Chen MF, Ker CG, Bornman PC, Hilvano SC, Kim SW, Liau KH, Kim MH. Diagnostic cri- CONCLUSION teria and severity assessment of acute cholangitis: Tokyo Ascending cholangitis is a treatable illness with Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):52- 8. Epub 2007 Jan 30. PubMed PMID: 17252297; PubMed practice guidelines in place to assist in guiding Central PMCID: PMC2784515. diagnosis, severity grading, antibiotic selection, 6. Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, and therapeutic intervention. Use of the diagnostic Gabata T, Hata J, Liau KH, Miura F, Horiguchi A, Liu KH, and severity grading criteria reliably identifies Su CH, Wada K, Jagannath P, Itoi T, Gouma DJ, Mori Y, Mukai S, Giménez ME, Huang WS, Kim MH, Okamoto K, patients and provides prognostic information. Belli G, Dervenis C, Chan ACW, Lau WY, Endo I, Gomi H, Antimicrobial selection is based on community Yoshida M, Mayumi T, Baron TH, de Santibañes E, Teoh isolate resistance patterns. ERCP remains the most AYB, Hwang TL, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Higuchi R, Kitano S, Inomata M, Deziel common procedure selected for biliary drainage. DJ, Jonas E, Hirata K, Sumiyama Y, Inui K, Yamamoto M. PTBD is an acceptable alternative, with EUS-BD Tokyo Guidelines 2018: diagnostic criteria and severity gaining acceptance as experience broadens. grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. doi: 10.1002/jhbp.512. Epub 2018 Jan 5. PubMed PMID: 29032610. 7. Kiriyama S, Takada T, Hwang TL, Akazawa K, Miura F, References Gomi H, Mori R, Endo I, Itoi T, Yokoe M, Chen MF, Jan YY, Ker CG, Wang HP, Wada K, Yamaue H, Miyazaki M, 1. Kimura Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Yamamoto M. Clinical application and verification of the Garden OJ, Büchler MW, Windsor JA, Mayumi T, Yoshida TG13 diagnostic and severity grading criteria for acute M, Miura F, Higuchi R, Gabata T, Hata J, Gomi H, Dervenis cholangitis: an international multicenter observational study. C, Lau WY, Belli G, Kim MH, Hilvano SC, Yamashita Y. J Hepatobiliary Pancreat Sci. 2017 Jun;24(6):329-337. doi: TG13 current terminology, etiology, and epidemiology of 10.1002/jhbp.458. Epub 2017 May 29. PubMed PMID: acute cholangitis and cholecystitis. J Hepatobiliary Pancreat 28419764. Sci. 2013 Jan;20(1):8-23. doi: 10.1007/s00534-012-0564-0. 8. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli Review. PubMed PMID: 23307004. M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally 2. Reuken PA, Torres D, Baier M, Löffler B, Lübbert C, ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane Lippmann N, Stallmach A, Bruns T. Risk Factors for D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Multi-Drug Resistant Pathogens and Failure of Empiric Coopersmith C, De Backer DP, French CJ, Fujishima S, First-Line Therapy in Acute Cholangitis. PLoS One. 2017 Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad Jan 11;12(1):e0169900. doi: 10.1371/journal.pone.0169900. DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini eCollection 2017. Erratum in: PLoS One. 2017 Feb 13;12 JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, (2):e0172373. PubMed PMID: 28076388; PubMed Central Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, PMCID: PMC5226732. Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, 3. Gomi H, Takada T, Hwang TL, Akazawa K, Mori R, Endo Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson I, Miura F, Kiriyama S, Matsunaga N, Itoi T, Yokoe M, SQ, Singer M, Thompson BT, Townsend SR, Van der Poll

PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 43 Current Management of Ascending Cholangitis FRONTIERS IN ENDOSCOPY, SERIES #47

T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. 18. Khashab MA, Tariq A, Tariq U, Kim K, Ponor L, Lennon Surviving Sepsis Campaign: International Guidelines for AM, Canto MI, Gurakar A, Yu Q, Dunbar K, Hutfless S, Management of Sepsis and : 2016. Intensive Kalloo AN, Singh VK. Delayed and unsuccessful endo- Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134- scopic retrograde cholangiopancreatography are associated 017-4683-6. Epub 2017 Jan 18. PubMed PMID: 28101605. with worse outcomes in patients with acute cholangitis. 9. Hawser SP, Bouchillon SK, Hoban DJ, Badal RE. In vitro Clin Gastroenterol Hepatol. 2012 Oct;10(10):1157-61. doi: susceptibilities of aerobic and facultative anaerobic Gram- 10.1016/j.cgh.2012.03.029. Epub 2012 Apr 13. PubMed negative bacilli from patients with intra-abdominal infec- PMID: 22507875. tions worldwide from 2005-2007: results from the SMART 19. Jang SE, Park SW, Lee BS, Shin CM, Lee SH, Kim study. Int J Antimicrob Agents. 2009 Dec;34(6):585-8. JW, Jeong SH, Kim N, Lee DH, Park JK, Hwang JH. doi: 10.1016/j.ijantimicag.2009.07.013. Epub 2009 Sep 11. Management for CBD stone-related mild to moderate acute PubMed PMID: 19748234. cholangitis: urgent versus elective ERCP. Dig Dis Sci. 2013 10. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Jul;58(7):2082-7. doi: 10.1007/s10620-013-2595-z. Epub Goldstein EJ, Baron EJ, O’Neill PJ, Chow AW, Dellinger EP, 2013 Mar 2. PubMed PMID: 23456495. Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens 20. Park CS, Jeong HS, Kim KB, Han JH, Chae HB, Youn SJ, AB, Sawyer RG, Bartlett JG. Diagnosis and management Park SM. Urgent ERCP for acute cholangitis reduces mor- of complicated intra-abdominal infection in adults and tality and hospital stay in elderly and very elderly patients. children: guidelines by the Surgical Infection Society and Hepatobiliary Pancreat Dis Int. 2016 Dec;15(6):619-625. the Infectious Diseases Society of America. Clin Infect Dis. PubMed PMID:27919851. 2010 Jan 15;50(2):133-64. doi: 10.1086/649554. Erratum in: 21. Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Clin Infect Dis. 2010 Jun 15;50(12):1695. Dosage error in Association between early ERCP and mortality in article text. PubMed PMID: 20034345. patients with acute cholangitis. Gastrointest Endosc. 2018 11. Wu PS, Chuang C, Wu PF, Lin YT, Wang FD. Anaerobic Jan;87(1):185-192. doi: 10.1016/j.gie.2017.04.009. Epub coverage as definitive therapy does not affect clinical- out 2017 Apr 20. PubMed PMID: 28433613. comes in community-onset bacteremic biliary tract infection 22. Parbhu SK, Siddiqui AA, Taylor LJ, Adler DG. Initial Report without anaerobic bacteremia. BMC Infect Dis. 2018 Jun of Outpatient Management of Acute Cholangitis via ERCP. 15;18(1):277. doi: 10.1186/s12879-018-3184-8. PubMed Dig Dis Sci. 2017 Jun;62(6):1676-1677. doi: 10.1007/ PMID: 29902981; PubMed Central PMCID: PMC6003161. s10620-017-4497-y. Epub 2017 Mar 17. PubMed PMID: 12. Lee JK, Park CW, Lee SH, Kang HW, Kwon JH, Kim JH, 28315026. Lim YJ, Kim ES, Koh MS, Lee JH. Updates in bacterio- 23. Karvellas CJ, Abraldes JG, Zepeda-Gomez S, Moffat DC, logical epidemiology of community-acquired severe acute Mirzanejad Y, Vazquez-Grande G, Esfahani EK, Kumar cholangitis and the effectiveness of metronidazole added A; Cooperative Antimicrobial Therapy of Septic Shock routinely to the first-line antimicrobial regimen. J Infect (CATSS) Database Research Group. The impact of delayed Chemother. 2013 Dec;19(6):1029-34. doi: 10.1007/s10156- biliary decompression and anti-microbial therapy in 260 013-0616-7. Epub 2013 May 25. PubMed PMID: 23708782. patients with cholangitis-associated septic shock. Aliment 13. Sung YK, Lee JK, Lee KH, Lee KT, Kang CI. The clini- Pharmacol Ther. 2016 Oct;44(7):755-66. doi: 10.1111/ cal epidemiology and outcomes of bacteremic biliary tract apt.13764. Epub 2016 Aug 10. PubMed PMID: 27506331. infections caused by antimicrobial-resistant pathogens. Am 24. Aboelsoud M, Siddique O, Morales A, Seol Y, Al-Qadi J Gastroenterol. 2012 Mar;107(3):473-83. doi: 10.1038/ M. Early biliary drainage is associated with favourable ajg.2011.387. Epub 2012 Feb 14. PubMed PMID: 22334249. outcomes in critically-ill patients with acute cholangi- 14. Lee F, Ohanian E, Rheem J, Laine L, Che K, Kim JJ. tis. Prz Gastroenterol. 2018;13(1):16-21. doi: 10.5114/ Delayed endoscopic retrograde cholangiopancreatography pg.2018.74557. Epub 2018 Mar 26. PubMed PMID: is associated with persistent organ failure in hospitalised 29657606; PubMed Central PMCID: PMC5894448. patients with acute cholangitis. Aliment Pharmacol Ther. 25. Mukai S, Itoi T, Baron TH, Takada T, Strasberg SM, Pitt HA, 2015 Jul;42(2):212-20. doi: 10.1111/apt.13253. Epub 2015 Ukai T, Shikata S, Teoh AYB, Kim MH, Kiriyama S, Mori May 22. PubMed PMID: 25997554. Y, Miura F, Chen MF, Lau WY, Wada K, Supe AN, Giménez 15. Navaneethan U, Gutierrez NG, Jegadeesan R, Venkatesh PG, ME, Yoshida M, Mayumi T, Hirata K, Sumiyama Y, Inui K, Butt M, Sanaka MR, Vargo JJ, Parsi MA. Delay in performing Yamamoto M. Indications and techniques of biliary drain- ERCP and adverse events increase the 30-day readmission age for acute cholangitis in updated Tokyo Guidelines 2018. risk in patients with acute cholangitis. Gastrointest Endosc. J Hepatobiliary Pancreat Sci. 2017 Oct;24(10):537-549. 2013 Jul;78(1):81-90. doi: 10.1016/j.gie.2013.02.003. Epub doi: 10.1002/jhbp.496. Epub 2017 Oct 5. PubMed PMID: 2013 Mar 23. PubMed PMID: 23528654. 28834389. 16. Parikh MP, Wadhwa V, Thota PN, Lopez R, Sanaka 26. ASGE Standards of Practice Committee, Chathadi KV, MR. Outcomes Associated With Timing of ERCP in Chandrasekhara V, Acosta RD, Decker GA, Early DS, Acute Cholangitis Secondary to Choledocholithiasis. Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher J Clin Gastroenterol. 2018 Jan 19. doi: 10.1097/ DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MCG.0000000000000982. [Epub ahead of print] PubMed MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman PMID: 29356786. JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, 17. Parikh MP, Gupta NM, Thota PN, Lopez R, Sanaka MR. DeWitt JM. The role of ERCP in benign diseases of the Temporal trends in utilization and outcomes of endoscopic biliary tract. Gastrointest Endosc. 2015 Apr;81(4):795-803. retrograde cholangiopancreatography in acute cholangitis doi: 10.1016/j.gie.2014.11.019. Epub 2015 Feb 7. PubMed due to choledocholithiasis from 1998 to 2012. Surg Endosc. PMID: 25665931. 2018 Apr;32(4):1740-1748. doi: 10.1007/s00464-017-5856- 27. Adler DG, Baron TH, Davila RE, Egan J, Hirota WK, 7. Epub 2017 Sep 15. PubMed PMID: 28917018. Leighton JA, Qureshi W, Rajan E, Zuckerman MJ, Fanelli

44 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 Current Management of Ascending Cholangitis FRONTIERS IN ENDOSCOPY, SERIES #47

R, Wheeler-Harbaugh J, Faigel DO; Standards of Practice Int Open. 2016 Apr;4(4):E487-96. doi: 10.1055/s-0042- Committee of American Society for Gastrointestinal 102648. Epub 2016 Mar 30. PubMed PMID: 27092334; Endoscopy. ASGE guideline: the role of ERCP in diseases PubMed Central PMCID: PMC4831932. of the biliary tract and the . Gastrointest Endosc. 36. Khashab MA, Valeshabad AK, Afghani E, Singh VK, 2005 Jul;62(1):1-8. PubMed PMID: 15990812. Kumbhari V, Messallam A, Saxena P, El Zein M, Lennon 28. Lai EC, Mok FP, Tan ES, Lo CM, Fan ST, You KT, Wong J. AM, Canto MI, Kalloo AN. A comparative evaluation of Endoscopic biliary drainage for severe acute cholangitis. N EUS-guided biliary drainage and percutaneous drainage in Engl J Med. 1992 Jun 11;326(24):1582-6. PubMed PMID: patients with distal malignant biliary obstruction and failed 1584258. ERCP. Dig Dis Sci. 2015 Feb;60(2):557-65. doi: 10.1007/ 29. Nennstiel S, Weber A, Frick G, Haller B, Meining A, Schmid s10620-014-3300-6. Epub 2014 Aug 1. PubMed PMID: RM, Neu B. Drainage-related Complications in Percutaneous 25081224. Transhepatic Biliary Drainage: An Analysis Over 10 Years. 37. Moole H, Bechtold ML, Forcione D, Puli SR. A meta- J Clin Gastroenterol. 2015 Oct;49(9):764-70. doi: 10.1097/ analysis and systematic review: Success of endoscopic MCG.0000000000000275. PubMed PMID: 25518004. ultrasound guided biliary stenting in patients with inop- 30. ASGE Standards of Practice Committee, Chandrasekhara erable malignant biliary strictures and a failed ERCP. V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Medicine (Baltimore). 2017 Jan;96(3):e5154. doi: 10.1097/ Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu MD.0000000000005154. Review. PubMed PMID: SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang 28099327; PubMed Central PMCID: PMC5279072. A, Wani SB, Yang J, DeWitt JM. Adverse events associated 38. Vila JJ, Pérez-Miranda M, Vazquez-Sequeiros E, Abadia with ERCP. Gastrointest Endosc. 2017 Jan;85(1):32-47. doi: MA, Pérez-Millán A, González-Huix F, Gornals J, Iglesias- 10.1016/j.gie.2016.06.051. Epub 2016 Aug 18. Review. Garcia J, De la Serna C, Aparicio JR, Subtil JC, Alvarez A, de PubMed PMID: 27546389. la Morena F, García-Cano J, Casi MA, Lancho A, Barturen 31. ASGE Technology Committee, Komanduri S, Thosani N, A, Rodríguez-Gómez SJ, Repiso A, Juzgado D, Igea F, Abu Dayyeh BK, Aslanian HR, Enestvedt BK, Manfredi Fernandez-Urien I, González-Martin JA, Armengol-Miró M, Maple JT, Navaneethan U, Pannala R, Parsi MA, Smith JR. Initial experience with EUS-guided cholangiopancrea- ZL, Sullivan SA, Banerjee S. Cholangiopancreatoscopy. tography for biliary and pancreatic duct drainage: a Spanish Gastrointest Endosc. 2016 Aug;84(2):209-21. doi: 10.1016/j. national survey. Gastrointest Endosc. 2012 Dec;76(6):1133- gie.2016.03.013. Epub 2016 May 26. Review. PubMed 41. doi: 10.1016/j.gie.2012.08.001. Epub 2012 Sep 26. PMID: 27236413. PubMed PMID: 23021167. 32. Téllez-Ávila FI, Herrera-Mora D, Duarte-Medrano G, Lopez- 39. Khashab MA, El Zein MH, Sharzehi K, Marson FP, Haluszka Arce G, Lindoro-Barraza D, Casanova I, Elizondo-Rivera J, O, Small AJ, Nakai Y, Park DH, Kunda R, Teoh AY, Peñas Ramírez-Luna M, Valdovinos-Andraca F. Biliary Drainage I, Perez-Miranda M, Kumbhari V, Van der Merwe S, Artifon in Patients With Failed ERCP: Percutaneous Versus EUS- EL, Ross AS. EUS-guided biliary drainage or enteroscopy- guided Drainage. Surg Laparosc Endosc Percutan Tech. 2018 assisted ERCP in patients with surgical anatomy and biliary Jun;28(3):183-187. doi: 10.1097/SLE.0000000000000528. obstruction: an international comparative study. Endosc PubMed PMID: 29683996. Int Open. 2016 Dec;4(12):E1322-E1327. Epub 2016 Aug 33. Itoi T, Itokawa F, Sofuni A, Kurihara T, Tsuchiya T, Ishii 30. PubMed PMID: 27995197; PubMed Central PMCID: K, Tsuji S, Ikeuchi N, Moriyasu F. Endoscopic ultrasound- PMC5161123. guided choledochoduodenostomy in patients with failed 40. Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. endoscopic retrograde cholangiopancreatography. World J Quality improvement guidelines for percutaneous transhe- Gastroenterol. 2008 Oct 21;14(39):6078-82. PubMed PMID: patic , biliary drainage, and percutaneous 18932289; PubMed Central PMCID: PMC2760181. cholecystostomy. J Vasc Interv Radiol. 2010 Jun;21(6):789- 34. Park DH, Koo JE, Oh J, Lee YH, Moon SH, Lee SS, Seo 95. doi: 10.1016/j.jvir.2010.01.012. Epub 2010 Mar 21. DW, Lee SK, Kim MH. EUS-guided biliary drainage with PubMed PMID: 20307987. one-step placement of a fully covered metal stent for malig- 41. Park JM, Kang CD, Lee M, Park SC, Lee SJ, Jeon nant biliary obstruction: a prospective feasibility study. Am YH, Cho SW. Percutaneous cholecystostomy for biliary J Gastroenterol. 2009 Sep;104(9):2168-74. doi: 10.1038/ decompression in patients with cholangitis and pancre- ajg.2009.254. Epub 2009 Jun 9. PubMed PMID: 19513026. atitis. J Int Med Res. 2018 Jan 1:300060518786632. doi: 35. Khashab MA, Van der Merwe S, Kunda R, El Zein MH, 10.1177/0300060518786632. [Epub ahead of print] PubMed Teoh AY, Marson FP, Fabbri C, Tarantino I, Varadarajulu S, PMID: 30027779. Modayil RJ, Stavropoulos SN, Peñas I, Ngamruengphong 42. Li YL, Wong KH, Chiu KW, Cheng AK, Cheung RK, Yam S, Kumbhari V, Romagnuolo J, Shah R, Kalloo AN, Perez- MK, Chan AL, Chan VS, Law MW, Lee PS. Percutaneous Miranda M, Artifon EL. Prospective international multicenter cholecystostomy for high-risk patients with acute chol- study on endoscopic ultrasound-guided biliary drainage for angitis. Medicine (Baltimore). 2018 May;97(19):e0735. patients with malignant distal biliary obstruction after failed doi: 10.1097/MD.0000000000010735. PubMed PMID: endoscopic retrograde cholangiopancreatography. Endosc 29742738; PubMed Central PMCID: PMC5959387.

PRACTICAL GASTROENTEROLOGY

PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 45