OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) may help detect cholangiocarcinoma in patients with primary sclerosing cholangitis (PSC), but it may be associated with complications. This study was aimed at determining the prognostic impact of ERCP on patients with PSC without cholangitis.
METHODS: Patients with PSC without cholangitis were divided into two groups: those who underwent ERCP within three years after diagnosis (ERCP-performed group) and those who did not (non-ERCP group). These groups were compared in terms of clinical outcomes (liver-related death or liver transplantation, endoscopic treatment requirement and repeated cholangitis) and the composite outcome.
RESULTS: Of 99 patients with PSC with detailed medical history, 49 were included in the ERCP-performed group and 21 in the non-ERCP group. In Kaplan-Meier analysis, the non-ERCP group was less likely to achieve the three outcomes and the composite outcome, showing statistical significance (endoscopic treatment requirement; p = 0.017 and composite outcome; p = 0.014). A Cox proportional hazards model indicated that ERCP in the asymptomatic state was a significant predictor of endoscopic treatment requirement (hazard ratio [HR]: 4.37, 95% confidence interval [CI]: 1.03-18.59) and the composite outcome (HR: 4.54, 95% CI: 1.07-19.28).
CONCLUSIONS: ERCP in patients with PSC without cholangitis is likely to require further endoscopic treatment and may be associated with poor prognosis.

Streptococcus pyogenes (S. pyogenes) is a gram-positive, facultative anaerobic bacterium that appears as cocci in chains and commonly causes skin infections and pharyngitis. Here, we present a very uncommon case of cholangitis associated with invasive S. pyogenes infection in a 34-year-old man with metastatic pancreatic adenocarcinoma who presented with fever, right upper quadrant pain, jaundice, altered mental status, and hypotension. The patient underwent a percutaneous transhepatic cholangiogram, showing moderate dilatation of intrahepatic biliary ducts with obstruction of the proximal common bile duct, and an internal/external biliary drain was placed to allow for the flow of bile. Blood cultures grew S. pyogenes. Biliary fluid culture obtained at the time of drain placement grew S. pyogenes, lactobacilli, and saccharomyces. The patient was treated with ampicillin-sulbactam and fluconazole. While the patient recovered from his sepsis, he died within weeks of diagnosis due to complications of metastatic disease.

The aim of this study was to investigate and characterize the microbiome in bile samples obtained from dogs with gallbladder mucocele (6), cats with suspected cholangitis/cholangiohepatitis (4), as well as from healthy dogs (6) and cats (4). Our goal was to compare the microbiome patterns with clinical findings and bacterial culture results in diseases of the gallbladder and to identify a potential microbial biomarker of diseased groups. The microbial taxa composition revealed that Proteobacteria were the most dominant phylum in healthy and diseased individuals in all groups. Individuals from six families including Burkholderiaceae, Phyllobacteriaceae, Bradyrhizobiaceae, Sphingomonadaceae, Moraxellaceae, and Caulobacteraceae, constituted the core microbiome in the gallbladder of healthy dogs. A combination of LEfSe analysis and Taxa2ASV decomposer revealed that Pseudomonaceae and Ruminococcaceae exclusively occurred in the mucocele group. In conclusion, this study determined the core microbiome in the gallbladder of healthy dogs and the possible biomarkers (Pseudomonaceae and Ruminococcaceae) of gallbladder mucocele in dogs.
Le but de cette étude était d’étudier et de caractériser le microbiome dans des échantillons de bile obtenus auprès de chiens atteints de mucocèle de la vésicule biliaire (6), de chats suspectés de cholangite/cholangiohépatite (4), ainsi que de chiens (6) et de chats en bonne santé (4). Notre objectif était de comparer les modèles de microbiome avec les résultats cliniques et les résultats de cultures bactériennes dans les maladies de la vésicule biliaire et d’identifier un biomarqueur microbien potentiel des groupes malades. La composition des taxons microbiens a révélé que les protéobactéries constituaient le phylum le plus dominant chez les individus sains et malades de tous les groupes. Des individus de six familles, dont Burkholderiaceae, Phyllobacteriaceae, Bradyrhizobiaceae, Sphingomonadaceae, Moraxellaceae et Caulobacteraceae, constituaient le microbiome central de la vésicule biliaire de chiens en bonne santé. Une combinaison de l’analyse LEfSe et du décomposeur Taxa2ASV a révélé que les Pseudomonaceae et les Ruminococcaceae étaient exclusivement présentes dans le groupe des mucocèles. En conclusion, cette étude a déterminé le microbiome central de la vésicule biliaire de chiens en bonne santé et les biomarqueurs possibles (Pseudomonaceae et Ruminococcaceae) de la mucocèle de la vésicule biliaire chez le chien.(Traduit par Docteur Serge Messier).

OBJECTIVE: Although the biliary tract is a common source of invasive infections, the epidemiology of cholangitis- and cholecystitis-associated bloodstream infection (BSI) is not well defined. The objective of this study was to determine the incidence, clinical determinants, microbiology of biliary tract-associated BSI, and predicted adequacy of common empiric therapy regimens.
METHODS: All biliary tract-associated BSI in Queensland during 2000-2019 were identified using state-wide data sources. Predicted adequacy of empiric antimicrobial therapy was determined according to microbiological susceptibility data.
RESULTS: There were 3,698 episodes of biliary tract-associated BSI occurred in 3,433 patients of which 2,147 (58.1%) episodes were due to cholangitis and 1,551 (41.9%) cholecystitis, for age- and sex-standardized incidence rates of 2.7, and 2.0 per 100,000 population, respectively. An increasing incidence of biliary tract-associated BSI was observed over the study that was attributable to an increase in cholangitis cases. There was a significant increased risk for biliary tract-associated BSI observed with advancing age and male sex. Patients with cholangitis were older, more likely to have healthcare associated infection, and have more comorbidities most notably liver disease and malignancies as compared to patients with cholecystitis. The distribution of infecting pathogens was significantly different with polymicrobial aetiologies more commonly observed with cholangitis (18.4% vs. 10.5%; p < 0.001). The combination of ampicillin/gentamicin/metronidazole was predicted to have the overall highest adequacy (96.1%), whereas amoxicillin/clavulanate had the lowest (77.0%). Amoxicillin/clavulanate (75.2% vs. 79.4%, p:0.03) and ceftriaxone/metronidazole (83.4% vs. 89.6%; p < 0.001) showed significantly inferior predicted adequacy for cholangitis as compared to cholecystitis.
CONCLUSIONS: Bloodstream infections related to cholecystitis and cholangitis exhibit different epidemiology, microbiology, and requirements for empiric therapy.

BACKGROUND: Glycoprotein-2 (GP2) IgA is a predictor of disease severity in primary sclerosing cholangitis (PSC). We examined GP2\'s occurrence in the biliary tract, the site of inflammation.
METHODS: GP2 was analyzed using ELISA, immunoblotting, mass spectrometry, and immunohistochemistry. The samples included: 20 bile and 30 serum samples from PSC patients, 23 bile and 11 serum samples from patients with gallstone disease (GD), 15 bile samples from healthy individuals undergoing liver-donation surgery (HILD), 20 extracts of gallstones (GE) obtained during cholecystectomy, and 101 blood-donor sera.
RESULTS: Biliary GP2 concentrations were significantly higher in patients with PSC and GD than in HILD (p < 0.0001). Serum GP2 levels were similar in PSC and GD patients, and controls, but lower than in bile (p < 0.0001). GP2 was detected in all 20 GEs. Mass spectrometry identified GP2 in the bile of 2 randomly selected GD and 2 PSC patients, and in none of 2 HILD samples. GP2 was found in peribiliary glands in 8 out of 12 PSC patients, showing morphological changes in acinar cells, but not in GD-gallbladders.
CONCLUSIONS: GP2 is present in bile of PSC and GD patients. It is synthesized in the peribiliary glands of PSC patients, supporting a pathogenic role for biliary GP2 in PSC.

OBJECTIVE: To describe the real-world treatment patterns of systemic therapies for biliary tract cancer (BTC) and to examine the frequency and management of biliary infection in Japan.
METHODS: Patients diagnosed with BTC and prescribed systemic therapy between January 2011 and September 2020 were retrieved from the Japanese Medical Data Vision database. The look-back period was set to 5 years. Patient characteristics, treatment patterns, and biliary infection-induced treatment interruption were analyzed.
RESULTS: The full analysis set comprised 22 742 patients with a mean age of 71.0 years and 61.6% were male. The most common BTC type was extrahepatic cholangiocarcinoma (44.6%). The three most common first-line regimens were S-1 monotherapy (33.0%), gemcitabine+cisplatin (32.5%), and gemcitabine monotherapy (18.7%) over the entire observation period (January 2011-September 2021). Patients who received monotherapies tended to be older. Biliary infection-induced treatment interruption occurred in 29.5% of patients, with a median time to onset of 64.0 (interquartile range 29.0-145.0) days. The median duration of intravenous antibiotics was 12.0 (interquartile range 4.0-92.0) days.
CONCLUSIONS: These results demonstrated potential challenges of BTC in Japanese clinical practice particularly use of multiple regimens, commonly monotherapies, which are not recommended as first-line treatment, and the management of biliary infections during systemic therapy.

UNASSIGNED: The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies.
UNASSIGNED: Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics.
UNASSIGNED: Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82-0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward.
UNASSIGNED: The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

UNASSIGNED: Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures.
UNASSIGNED: This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004-3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant.
UNASSIGNED: Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37).
UNASSIGNED: Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.
UNASSIGNED: Bei der akuten Pankreatitis handelt es sich um eine gastrointestinale Akuterkrankung, die anhand von typischer Symptomatik, erhöhter Serumlipase und abdomineller Bildgebung diagnostiziert werden kann. Durch Organversagen und lokale Komplikationen weisen schwere Verläufe eine hohe Sterblichkeit auf und erfordern häufig eine Behandlung auf der Intensivstation. Letztlich kann die Prognose von Patienten mit schwerer akuter Pankreatitis nur durch eine optimale interdisziplinäre Behandlung verbessert werden. Dieser Artikel gibt einen Überblick über die die initiale diagnostische und ätiologische Abklärung sowie über die Beurteilung von Organversagen und Abschätzung des Schweregrads gemäß gebräuchlicher Klassifikationssysteme. Ebenso werden das endoskopische Management bei biliärer Genese und von infizierten Nekrosen besprochen und die Grundzüge der zielgerichteten Volumentherapie, der Ernährungsstrategie und der Indikation zur antibiotischen Therapie erläutert.

With the widespread use of immune checkpoint inhibitors (ICIs), liver injury (ICI-induced liver injury) as an immune-related adverse event has become a major concern in clinical practice. Because severe cases of liver injury require administration of corticosteroids, a comprehensive evaluation is crucial, including clinical course, blood and imaging tests, and if necessary, pathological examination through liver biopsy. As with liver injury induced by other drugs, classification of injury type by R-value is useful in deciding treatment strategies for ICI-induced liver injury. Histologically, the most representative feature is an acute hepatitis-like hepatocellular injury, characterized by diffuse lobular inflammation accompanied by CD8-positive T lymphocytes. Another condition that can cause liver injury during ICI treatment is cholangitis accompanied by non-obstructive bile duct dilatation and bile duct wall thickening. Many cases of ICI-induced cholangitis are classified as non-hepatocellular injury type, and they have been reported to respond poorly to corticosteroids. It is essential that gastroenterologists/hepatologists and doctors in various departments work in cooperation to develop a system that achieves early diagnosis and appropriate treatment of ICI-induced liver injury.