DOCSLIB.ORG

Or Ascending Cholangitis) Is a Clinical Syndrome That Is Classically Characterized by the Triad Of

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Or Ascending Cholangitis) Is a Clinical Syndrome That Is Classically Characterized by the Triad Of ACUTE ASCENDING CHOLANGITIS Introduction Acute cholangitis (or ascending cholangitis) is a clinical syndrome that is classically characterized by the triad of: ● Fever ● Abdominal pain ● Jaundice The condition occurs as a result of obstruction/ stasis and subsequent infection within the biliary tract. In the absence of appropriate treatment the condition has significant potential for mortality and morbidity. It is a medical emergency that requires prompt antibiotic treatment and urgent relief of biliary obstruction (usually by endoscopic retrograde cholangiopancreatography ERCP). History Jean M. Charcot was the first to describe this illness in 1877. He described a triad of fever, jaundice, and right upper quadrant pain. Epidemiology Acute cholangitis is predominantly seen in adults, most commonly around 40-70 years of age. Physiology Normal barrier mechanisms to cholangitis infection include ● The sphincter of Oddi, which normally forms an effective mechanical barrier to duodenal reflux and ascending bacterial infection. ● Continuous flushing action of bile plus the bacteriostatic activity of bile salts which help maintain bile sterility. ● Secretory IgA and biliary mucous probably also function as anti-adherence factors, preventing bacterial colonization Pathology Organisms: Ascending cholangitis is usually associated with Gram-negative or anaerobic sepsis. ● Aerobic organisms include Escherichia coli and Klebsiella and Enterococcus species. ● The most common anaerobic organism is Bacteroides fragilis. Clostridia may also cause serious infection. Causes: Ascending cholangitis essentially occurs as consequence of obstruction of the biliary tract. Stasis leads to secondary bacterial infection; the organisms typically ascending from the duodenum. Biliary obstruction raises intrabiliary pressure and leads to increased permeability of bile ductules, permitting translocation of bacteria and toxins from the portal circulation into the biliary tract. Elevated pressures also favour migration of bacteria from bile into the systemic circulation, increasing the risk of septicaemia. Hematogenous spread from the portal vein may also occur but this is much less common. The causes of biliary tract obstruction include: ● Choledocholithiasis ● Biliary tract manipulations/interventions and stents, (usually for malignant obstructions). ● Hepatobiliary malignancies ● Benign stenosis, (previous scarring). ● Primary sclerosing cholangitis Complications; These include: ● Rupture and peritonitis ● Septicemia and septic shock ● Acute renal failure Cholecystitis ● Pyogenic liver abscess Clinical features Important points of history: Important points to o note on history will include: ● Past history of gallstones ● Recent history of biliary tract manipulations/ stents ● Any past history of biliary tract disease in general. ● Known Hepatobiliary tract malignancy Important points of examination: The “classic” presentation is of “Charcot’s triad”, consisting of: ● Fever ● Abdominal pain, (right upper quadrant). ● Jaundice Only 50 - 75% of patients however will present with all three features, most commonly of the group that do not, will have abdominal pain and fever (but not jaundice). Patients with more severe illness - suppurative cholangitis - may show additional confusion/ altered conscious state and hypotension - so called “Reynolds’s pentad”, which is associated with significant morbidity and mortality Ultimately septic shock and multiorgan failure can lead to death. Differential diagnoses: There are many, but the principle ones will include: ● Cholecystitis ● Biliary leaks, (following laparoscopic cholecystectomy). ● Right lower lobe pneumonias ● Pancreatitis ● Diverticulitis ● Hepatitis ● Liver abscess Investigations Blood tests: 1. FBE ● Elevated WCC and neutrophilia 2. CRP: ● This will be elevated. 3. U&Es/ glucose 4. LFTs: ● Elevated bilirubin and liver enzymes: ♥ This will be a cholestatic pattern with elevations in the serum alkaline phosphatase, gamma-glutamyl transpeptidase (GGT), and bilirubin (predominantly conjugated). ♥ In severe illness however an acute hepatocyte necrosis pattern can be can be seen with aminotransferase levels as high as 2000 IU/L 5. Lipase: ● There may be an associated obstructive pancreatitis. 5. Coagulation profile 6. Blood cultures: ● Cultures should also be obtained from bile or stents removed at endoscopic retrograde cholangiopancreatography (ERCP). Ultrasound An ultrasound examination to confirm ● Biliary tract obstruction ● Gallstones: ♥ The highest risk for severe sepsis will come from impacted stones. ● Associated pathology: cholecystitis, liver abscess. If the patient is at high risk for complications from ERCP endoscopic ultrasound is a further option to look for evidence of bile duct stones or obstruction, MRCP If the transabdominal ultrasound is normal, magnetic resonance cholangio- pancreatography (MRCP) can be utilized. This is to look for bile duct stones or alternative diagnoses that may have been missed on transabdominal ultrasound. ERCP Endoscopic retrograde cholangio-pancreatography (ERCP) is both diagnostic and therapeutic. It is the best imaging first up in unwell patients, (especially if abnormal LFTs) because of its ability to therapeutically intervene. Management The prognosis is variable depending on the degree of illness, the co-morbidities and the underlying cause of the obstruction. The best chance of a good outcome, other factors being equal will depend on early antibiotic treatment and appropriate drainage and decompression of biliary tract. 1. Analgesia: ● Pain is usually significant and titrated IV opioids will be necessary. 2. Nil by mouth 3. Fluid resuscitation: ● IV fluid resuscitation will often be required. 4. Antibiotics: Some patients with acute cholangitis will respond to conservative management with antibiotic therapy. Biliary drainage can then be performed on a semi-elective basis (within 24 to 48 hours) Options include: ● Tazocin and metronidazole If sensitive to penicillin, (but not life-threatening) ● Ceftriaxone and metronidazole If life-threatening penicillin reaction: ● Ciprofloxacin and metronidazole If the patient does not improve over the first 24 hours with conservative management, urgent biliary decompression is required. See latest Antibiotic Guidelines for full prescribing details. 5. Endoscopic drainage: ● If the ultrasound shows ductal dilation or stones, it should be followed promptly (within 24 hours, but earlier if the patient is particularly unwell) by ERCP to provide biliary drainage. ● Endoscopic drainage has largely replaced emergency surgical common duct exploration and T-tube drainage as standard treatment. ● Endoscopic sphincterotomy with stone extraction and/or stent insertion (depending on the cause of the obstruction) is the treatment of choice for establishing biliary drainage in acute cholangitis Patients who require urgent drainage are those with signs of acute suppurative cholangitis, including: ● Persistent / intractable abdominal pain ● High fever (> 38.5) ● Hypotension despite adequate resuscitation ● Mental confusion (a predictor of poor outcome) 6. Percutaneous transhepatic cholangiography: ● Occasionally ERCP is not technically feasible or fails to establish biliary drainage. In such cases, biliary drainage can often be achieved by percutaneous transhepatic cholangiography. 7. Open surgical decompression: ● Surgical decompression is done for patients in whom endoscopic drainage is unsuccessful or unavailable. 8. Supportive: ● Supportive treatments are provided as required. Hypoxemia and hypotension as well as renal support may need to addressed References 1. Antibiotic Therapeutic Guidelines, 14th ed 2010. 2. Nezam H Afdhal et al. Acute cholangitis in Up to Date Website October 2013. Dr J.Hayes October 2013. .
Load more

Recommended publications
  • Diagnosis and Treatment of Perianal Crohn Disease: NASPGHAN Clinical Report and Consensus Statement
    CLINICAL REPORT Diagnosis and Treatment of Perianal Crohn Disease: NASPGHAN Clinical Report and Consensus Statement ÃEdwin F. de Zoeten, zBrad A. Pasternak, §Peter Mattei, ÃRobert E. Kramer, and yHoward A. Kader ABSTRACT disease. The first description connecting regional enteritis with Inflammatory bowel disease is a chronic inflammatory disorder of the perianal disease was by Bissell et al in 1934 (2), and since that time gastrointestinal tract that includes both Crohn disease (CD) and ulcerative perianal disease has become a recognized entity and an important colitis. Abdominal pain, rectal bleeding, diarrhea, and weight loss consideration in the diagnosis and treatment of CD. Perianal characterize both CD and ulcerative colitis. The incidence of IBD in the Crohn disease (PCD) is defined as inflammation at or near the United States is 70 to 150 cases per 100,000 individuals and, as with other anus, including tags, fissures, fistulae, abscesses, or stenosis. autoimmune diseases, is on the rise. CD can affect any part of the The symptoms of PCD include pain, itching, bleeding, purulent gastrointestinal tract from the mouth to the anus and frequently will include discharge, and incontinence of stool. perianal disease. The first description connecting regional enteritis with perianal disease was by Bissell et al in 1934, and since that time perianal INCIDENCE AND NATURAL HISTORY disease has become a recognized entity and an important consideration in the Limited pediatric data describe the incidence and prevalence diagnosis and treatment of CD. Perianal Crohn disease (PCD) is defined as of PCD. The incidence of PCD in the pediatric age group has been inflammation at or near the anus, including tags, fissures, fistulae, abscesses, estimated to be between 13.6% and 62% (3).
    [Show full text]
  • Choledochoduodenal Fistula Complicatingchronic
    Gut: first published as 10.1136/gut.10.2.146 on 1 February 1969. Downloaded from Gut, 1969, 10, 146-149 Choledochoduodenal fistula complicating chronic duodenal ulcer in Nigerians E. A. LEWIS AND S. P. BOHRER From the Departments ofMedicine and Radiology, University ofIbadan, Nigeria Peptic ulceration was thought to be rare in Nigerians SOCIAL CLASS All the patients were in the lower until the 1930s when Aitken (1933) and Rose (1935) socio-economic class. This fact may only reflect the reported on this condition. Chronic duodenal ulcers, patients seen at University College Hospital. in particular, are being reported with increasing frequency (Ellis, 1948; Konstam, 1959). The symp- AETIOLOGY Twelve (92.3 %) of the fistulas resulted toms and complications of duodenal ulcers in from chronic duodenal ulcer and in only one case Nigerians are the same as elsewhere, but the relative from gall bladder disease. incidence of these complications differs markedly. Pyloric stenosis is the commonest complication CLINICAL FEATURES There were no special symp- followed by haematemesis and malaena in that order toms or signs for this complication. All patients (Antia and Solanke, 1967; Solanke and Lewis, except the one with gall bladder disease presented 1968). Perforation though present is not very com- with symptoms of chronic duodenal ulcer or with mon. those of pyloric stenosis of which theie were four A remarkable complication found in some of our cases. In the case with gall bladder disease the history patients with duodenal ulcer who present them- was short and characterized by fever, right-sided selves for radiological examination is the formation abdominal pain, jaundice, and dark urine.
    [Show full text]
  • Descriptive Study Regarding the Etiological Factors Responsible for Secondary Bacterial Peritonitis in Patients Admitted in a Te
    International Journal of Health Sciences and Research Vol.10; Issue: 7; July 2020 Website: www.ijhsr.org Original Research Article ISSN: 2249-9571 Descriptive Study Regarding the Etiological Factors Responsible for Secondary Bacterial Peritonitis in Patients Admitted in a Tertiary Care Hospital in Trans Himalayan Region Raj Kumar1, Rahul Gupta2, Anjali Sharma3, Rajesh Chaudhary4 1MS General Surgery, Civil Hospital Baijnath, Himachal Pradesh 2MD Community Medicine, District Programme Officer, Health and Family Welfare, Himachal Pradesh 3Resident Doctor, Department of Microbiology, DRPGMC Kangra at Tanda, Himachal Pradesh 4MS General Surgery, Civil Hospital Nagrota Bagwan, Himachal Pradesh Corresponding Author: Rahul Gupta ABSTRACT Peritonitis is an inflammation of the peritoneum. Primary peritonitis which is spontaneous bacterial peritonitis, Secondary peritonitis due to infection from intraabdominal source or spillage of its contents and Tertiary peritonitis which is recurrent or reactivation of secondary peritonitis. The present study was aimed to determine the etiology of generalized secondary peritonitis among the patients admitted in Department of General Surgery, Dr RPGMC Kangra at Tanda. This descriptive observational study was conducted in the department of surgery Dr. Rajendra Prasad Government Medical College Kangra at Tanda consisting of patients having acute generalised secondary peritonitis presented in emergency department or Surgery outdoor patient department over a period of one year from December 2016 through November 2017. The most common etiology of generalized secondary peritonitis in our patients was peptic ulcer disease (77.13%) followed by perforated appendicitis (9.8%). Etiological factors of secondary generalised peritonitis have a different pattern in different geographical regions. Peptic ulcer disease remains the commonest etiology of secondary peritonitis in India followed by enteric perforation which is in contrast to the western studies where appendicular and colon perforations are more common.
    [Show full text]
  • Imaging of Biliary Infections
    3 Imaging of Biliary Infections Onofrio Catalano, MD1 Ronald S. Arellano, MD2 1 Division of Abdominal Imaging, Department of Radiology, Address for correspondence Onofrio Catalano, MD, Division of Massachusetts General Hospital, Harvard Medical School, Abdominal Imaging, Department of Radiology, Massachusetts Boston, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, 2 Division of Interventional Radiology, Department of Radiology, Boston, MA 02114 (e-mail: [email protected]). Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Dig Dis Interv 2017;1:3–7. Abstract Biliary tract infections cover a wide spectrum of etiologies and clinical presentations. Imaging plays an important role in understanding the etiology and as well as the extent Keywords of disease. Imaging also plays a vital role in assessing treatment response once a ► biliary infections diagnosis is established. This article will review the imaging findings of commonly ► cholangitides encountered biliary tract infectious diseases. ► parasites ► immunocompromised ► echinococcal Infections of the biliary tree can have a myriad of clinical and duodenum can lead toa cascade ofchanges tothehost immune imaging manifestations depending on the infectious etiolo- defense mechanisms of chemotaxis and phagocytosis.7 The gy, underlying immune status of the patient and extent of resultant lackof bile and secretory immunoglobulin A from the involvement.1,2 Bacterial infections account for the vast gastrointestinal tract lead
    [Show full text]
  • PERFORATED PEPTIC ULCER. Patient Usually Experiences
    Postgrad Med J: first published as 10.1136/pgmj.12.134.470 on 1 December 1936. Downloaded from 470 POST-GRADUATE MEDICAL JOURNAL December, 1936 PERFORATED PEPTIC ULCER. By RONALD W. RAVEN, F.R.C.S. (Assistant Surgeon to T'he French Hospital, Assistant Surgeon to The Gordon Hospital for Rectal Diseases and Swrgical Registrar to The Royal Cancer Hospital.) INTRODUCTION. Peptic ulceration is a crippling disease judged from the stand-point of morbidity, and is also dangerous to life on account of serious complications, such as haemorrhage or perforation which may supervene during the course of the disease. These complications may occur in any patient and there are no criteria which will indicate whether or not an ulcer will bleed or perforate. When the treatment of peptic ulceration is under review it must be remembered that from 20 to 30 per cent. of these ulcers perforate. In a large series of cases I found that the incidence of perforation was 27 per cent. It is thus essential that patients suffering with peptic ulcer should be kept under continuous careful observation. Unfortunately, however, a small percentage of patients give no previous history of the peptic ulcer syndrome and perforation of the ulcer is the first indication of its presence. Recently, when considering the role of surgery in the treatment of chronic peptic ulcer, Joll stated that there has been a rise in the incidence of perforation as a complication of peptic ulcer since medical treatment has become systematized in the treatment of this disease. It must also be remembered that medical treat- Protected by copyright.
    [Show full text]
  • Case Report: a Patient with Severe Peritonitis
    Malawi Medical Journal; 25(3): 86-87 September 2013 Severe Peritonitis 86 Case Report: A patient with severe peritonitis J C Samuel1*, E K Ludzu2, B A Cairns1, What is the likely diagnosis? 2 1 What may explain the small white nodules on the C Varela , and A G Charles transverse mesocolon? 1 Department of Surgery, University of North Carolina, Chapel Hill NC USA 2 Department of Surgery, Kamuzu Central Hospital, Lilongwe Malawi Corresponding author: [email protected] 4011 Burnett Womack Figure1. Intraoperative photograph showing the transverse mesolon Bldg CB 7228, Chapel Hill NC 27599 (1a) and the pancreas (1b). Presentation of the case A 42 year-old male presented to Kamuzu Central Hospital for evaluation of worsening abdominal pain, nausea and vomiting starting 3 days prior to presentation. On admission, his history was remarkable for four similar prior episodes over the previous five years that lasted between 3 and 5 days. He denied any constipation, obstipation or associated hematemesis, fevers, chills or urinary symptoms. During the first episode five years ago, he was evaluated at an outlying health centre and diagnosed with peptic ulcer disease and was managed with omeprazole intermittently . His past medical and surgical history was non contributory and he had no allergies and he denied alcohol intake or tobacco use. His HIV serostatus was negative approximately one year prior to presentation. On examination he was afebrile, with a heart rate of 120 (Fig 1B) beats/min, blood pressure 135/78 mmHg and respiratory rate of 22/min. Abdominal examination revealed mild distension with generalized guarding and marked rebound tenderness in the epigastrium.
    [Show full text]
  • Digestive Tract Tuberculosis
    World Gastroenterology Organisation Global Guidelines Digestive tract tuberculosis March 2021 WGO Review Team Mohamed Tahiri (Chair, Morocco), K.L. Goh (Co-Chair, Malaysia), Zaigham Abbas (Pakistan), David Epstein (South Africa), Chen Min-Hu (China), Chris Mulder (Netherlands), Amarender Puri (India), Michael Schultz (New Zealand), Anton LeMair (Netherlands) Funding and conflict of interest statement All of the authors have stated that there were no conflicts of interest in relation to their authorship of this paper. Anton LeMair acts as guideline development consultant for WGO. WGO Global Guidelines Digestive tract tuberculosis 2 Contents 1 Introduction .............................................................................................................................. 4 1.1 About WGO cascades ................................................................................................................. 5 1.2 Definitions .................................................................................................................................. 5 1.3 Epidemiology .............................................................................................................................. 6 1.3.1 WHO 2018 global tuberculosis report .............................................................................. 6 1.4 Etiopathogenesis and risk factors .............................................................................................. 7 2 Clinical features .......................................................................................................................
    [Show full text]
  • Clinical Biliary Tract and Pancreatic Disease
    Clinical Upper Gastrointestinal Disorders in Urgent Care, Part 2: Biliary Tract and Pancreatic Disease Urgent message: Upper abdominal pain is a common presentation in urgent care practice. Narrowing the differential diagnosis is sometimes difficult. Understanding the pathophysiology of each disease is the key to making the correct diagnosis and providing the proper treatment. TRACEY Q. DAVIDOFF, MD art 1 of this series focused on disorders of the stom- Pach—gastritis and peptic ulcer disease—on the left side of the upper abdomen. This article focuses on the right side and center of the upper abdomen: biliary tract dis- ease and pancreatitis (Figure 1). Because these diseases are regularly encountered in the urgent care center, the urgent care provider must have a thorough understand- ing of them. Biliary Tract Disease The gallbladder’s main function is to concentrate bile by the absorption of water and sodium. Fasting retains and concentrates bile, and it is secreted into the duodenum by eating. Impaired gallbladder contraction is seen in pregnancy, obesity, rapid weight loss, diabetes mellitus, and patients receiving total parenteral nutrition (TPN). About 10% to 15% of residents of developed nations will form gallstones in their lifetime.1 In the United States, approximately 6% of men and 9% of women 2 have gallstones. Stones form when there is an imbal- ©Phototake.com ance in the chemical constituents of bile, resulting in precipitation of one or more of the components. It is unclear why this occurs in some patients and not others, Tracey Q. Davidoff, MD, is an urgent care physician at Accelcare Medical Urgent Care in Rochester, New York, is on the Board of Directors of the although risk factors do exist.
    [Show full text]
  • A Case Series on Intussusceptions in Infants Presenting with Listlessness
    ABDOMINAL CONDITIONS © 2010 SNL All rights reserved A case series on intussusceptions in infants presenting with listlessness Intussusception is characterised by abdominal pain, vomiting and blood in stools. However, in younger infants it may present with non-classical symptoms such as listlessness, pallor, decreased feeding, and being non-specifically unwell. Three cases of intussusception in young infants who presented with being listless and had some or no features to suggest a clinical diagnosis of intussusception are described which are designed to highlight the non-classical features of intussusception likely to be encountered in very young infants. Siba P. Paul1 ntussusception is one of the most tachycardia and prolonged capillary refill MBBS, DCH Icommon surgical emergencies time he was given a fluid bolus of 20mL/kg Paediatric Trust Registrar encountered in infancy and early with 0.9% sodium chloride. He was [email protected] childhood. This is a condition where the intermittently responding to his parents proximal segment of the bowel telescopes but was not irritable. His cardiovascular 1 David C. A. Candy into the distal segment causing and respiratory examination was MBBS, MSc, MD, FRCP, FRCPCH, FCU obstruction1. The classic triad of symptoms otherwise normal. Consultant Paediatric Gastroenterologist consists of abdominal pain, vomiting and He was distressed by an abdominal blood in stools1. It is often seen in children Nikila Pandya2 examination and was found to be drawing aged four months to two years, with a peak up his legs and crying while being MD, DCH, FRCPCH incidence during four to nine months of Consultant Paediatrician examined. The provisional diagnosis at age2.
    [Show full text]
  • A Challenging Case of Recurrent Eosinophilic Peritonitis
    Open Access Case Report DOI: 10.7759/cureus.9422 A Challenging Case of Recurrent Eosinophilic Peritonitis Myra Nasir 1 , Jasmin Hundal 1 , Arish Noor 1 , Juan Jose Chango Azanza 1 , Jaimy Villavicencio 1 1. Internal Medicine, University of Connecticut, Farmington, USA Corresponding author: Myra Nasir, [email protected] Abstract Eosinophilic peritonitis is a rare presentation of eosinophilic gastroenteritis and is characterized by eosinophil-rich inflammation in any part of the gastrointestinal tract in the absence of secondary causes of eosinophilia. We report a case of a 48-year-old female who had recurrent hospital admissions due to abdominal pain and distension secondary to relapsing eosinophilic peritonitis. Categories: Allergy/Immunology, Gastroenterology Keywords: idiopathic eosinophilic peritonitis, eosinophilic gastroenteritis, ascites Introduction Eosinophilic peritonitis (EP) is a rare presentation of eosinophilic gastroenteritis (EGE) [1]. Patients often present with abdominal distension, which can be accompanied by nausea, vomiting, diarrhea, and abdominal pain. The pathogenesis is poorly understood. We report the case of a 48-year-old female who had recurrent admissions for abdominal pain and distension and was found to have eosinophilic cholecystitis and EP. Case Presentation A 48-year-old female with a past medical history significant for asthma and bronchitis presented to the hospital in October 2018 with worsening abdominal pain associated with abdominal distension evolving over three weeks and diarrhea for three days. One month prior to this, she had undergone cholecystectomy, with tissue biopsy revealing eosinophilic cholecystitis (Figure 1). Her medications included furosemide 20 mg and pantoprazole 40 mg daily. She denied using any over-the-counter or herbal medications. Physical examination revealed a distended abdomen, diffusely tender to palpation.
    [Show full text]
  • Abdominal Pain
    10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group.
    [Show full text]
  • The Digestive Tract As the Origin of Systemic Inflammation Petrus R
    de Jong et al. Critical Care (2016) 20:279 DOI 10.1186/s13054-016-1458-3 REVIEW Open Access The digestive tract as the origin of systemic inflammation Petrus R. de Jong1,2*, José M. González-Navajas3,4 and Nicolaas J. G. Jansen1 Abstract Failure of gut homeostasis is an important factor in the pathogenesis and progression of systemic inflammation, which can culminate in multiple organ failure and fatality. Pathogenic events in critically ill patients include mesenteric hypoperfusion, dysregulation of gut motility, and failure of the gut barrier with resultant translocation of luminal substrates. This is followed by the exacerbation of local and systemic immune responses. All these events can contribute to pathogenic crosstalk between the gut, circulating cells, and other organs like the liver, pancreas, and lungs. Here we review recent insights into the identity of the cellular and biochemical players from the gut that have key roles in the pathogenic turn of events in these organ systems that derange the systemic inflammatory homeostasis. In particular, we discuss the dangers from within the gastrointestinal tract, including metabolic products from the liver (bile acids), digestive enzymes produced by the pancreas, and inflammatory components of the mesenteric lymph. Keywords: Acute inflammation, Gastrointestinal failure, Gut-liver crosstalk, Pancreatitis Abbreviations: ARDS, Acute respiratory distress syndrome; CCK, Cholecystokinin; DCA, Deoxycholic acid; FFA, Free fatty acid; G-I, Gastro-intestinal; GPR, G-protein-coupled receptor;
    [Show full text]