今日の臨床サポート

急性胆管炎

著者: 横江正道 名古屋第二赤十字病院 総合内科

監修: 真弓俊彦 産業医科大学 救急医学

著者校正/監修レビュー済:2021/07/14
参考ガイドライン:
  1. 日本肝胆膵外科学会/日本腹部救急医学会/日本胆道学会/日本外科感染症学会/日本医学放射線学会急性胆管炎・胆嚢炎診療ガイドライン2018
  1. Tokyo Guidelines 2018: updated Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis.
  1. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos).
  1. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis.
  1. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis.
  1. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis.
患者向け説明資料

概要・推奨   

  1. 急性胆管炎の診断に当たっては、シャルコー3徴が有用であるとされているが、3徴すべてがそろうことは少ないため、シャルコー3徴がそろわないからといって診断を除外することは推奨しない(推奨度3)。
  1. 急性胆管炎を診断するために行う血液検査では、CBC、AST、ALT、ALP、γ-GTP、BUN、Cr、T-Bil、CRPを選択することを強く推奨する(推奨度1)。
  1. 急性胆管炎の診療を行う際は、急性膵炎の鑑別ならびに併発を考慮して、アミラーゼ、リパーゼの採血が行われることは強く推奨される(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
横江正道 : 特に申告事項無し[2021年]
監修:真弓俊彦 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、BILE criteriaについて加筆を行った。

病態・疫学・診察

疾患情報  
  1. 急性胆管炎とは、胆管の胆汁が感染を起こした状態である。
  1. 急性胆管炎の診断基準は、「急性胆管炎・胆嚢炎診療ガイドライン2018」[1]「Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos).」[2]では、下記の項目のAのいずれか+BもしくはCのいずれかを認めるものを疑診、Aのいずれか+Bのいずれか+Cのいずれかを認めるものが確診となる。
  1. A)全身の炎症所見: 
  1. A-1:発熱(悪寒戦慄を伴うこともある)、A-2:血液検査;炎症反応所見
  1. B)胆汁うっ滞所見: 
  1. B-1:黄疸、B-2:血液検査;肝機能検査異常
  1. C)胆管病変の画像所見: 
  1. C-1:胆管拡張、C-2:胆管炎の成因;胆管狭窄、胆管結石、ステントなど
  1. シャルコー3徴は、3徴すべてそろうことは多くないので注意が必要である。
  1. 「急性胆管炎・胆嚢炎診療ガイドライン2018」ならびにTG18/TG13の診断基準には血液検査や画像所見も加わっている。診断に必要な検査項目を含めた検査(WBC、CRP、AST、ALT、ALP、γ-GTP、腹部エコーまたはCT)を行う。
  1. 診断に当たって最初に行われるべき画像検査は腹部エコーである。
問診・診察のポイント  
  1. 急性胆管炎を疑う場合は、胆道疾患の既往歴をきちんと聴取する。手術歴や内視鏡治療歴、ステント挿入なども把握すべきである。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Seiki Kiriyama, Kazuto Kozaka, Tadahiro Takada, Steven M Strasberg, Henry A Pitt, Toshifumi Gabata, Jiro Hata, Kui-Hin Liau, Fumihiko Miura, Akihiko Horiguchi, Keng-Hao Liu, Cheng-Hsi Su, Keita Wada, Palepu Jagannath, Takao Itoi, Dirk J Gouma, Yasuhisa Mori, Shuntaro Mukai, Mariano Eduardo Giménez, Wayne Shih-Wei Huang, Myung-Hwan Kim, Kohji Okamoto, Giulio Belli, Christos Dervenis, Angus C W Chan, Wan Yee Lau, Itaru Endo, Harumi Gomi, Masahiro Yoshida, Toshihiko Mayumi, Todd H Baron, Eduardo de Santibañes, Anthony Yuen Bun Teoh, Tsann-Long Hwang, Chen-Guo Ker, Miin-Fu Chen, Ho-Seong Han, Yoo-Seok Yoon, In-Seok Choi, Dong-Sup Yoon, Ryota Higuchi, Seigo Kitano, Masafumi Inomata, Daniel J Deziel, Eduard Jonas, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. doi: 10.1002/jhbp.512. Epub 2018 Jan 5.
Abstract/Text Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29032610  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. doi・・・
著者: Pamela A Lipsett, Henry A Pitt
雑誌名: Front Biosci. 2003 Sep 1;8:s1229-39. Epub 2003 Sep 1.
Abstract/Text Acute cholangitis is an infectious disease of the biliary tract with a wide spectrum of presentation ranging in severity from a mild form with fever and jaundice, to a severe form with septic shock. Supportive care with hydration, antibiotics, and biliary decompression remain the cornerstones of care. Broad-spectrum antibiotics should include coverage of E.coli, Klebsiella sp., Enterococcus sp., and in severely critically ill patients, coverage of additional pathogens such as Bacteriodes sp., Pseudomonas, and yeast should be considered. Biliary decompression should be performed early in the course of the illness when the patient has not improved or if they worsen with hydration and antibiotics. Stable patients should have biliary decompression usually within 72 hours when the fever has resolved. Urgent decompression with a percutaneous or endoscopic stent is preferred over an operative decompression in most institutions. Outcome is dependent on the etiology of the obstruction (benign versus malignant) and the ability to achieve biliary decompression.

PMID 12957832  Front Biosci. 2003 Sep 1;8:s1229-39. Epub 2003 Sep 1.
著者: Philippus C Bornman, Johan I van Beljon, Jake E J Krige
雑誌名: J Hepatobiliary Pancreat Surg. 2003;10(6):406-14. doi: 10.1007/s00534-002-0710-1.
Abstract/Text Acute cholangitis remains a life-threatening complication of biliary obstruction, particularly in the elderly with comorbid disease or when there is a delay in diagnosis and treatment. The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broad-spectrum antibiotics. The choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available. The timing and choice of biliary decompression varies depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause. Biliary sepsis resolves in most patients with conservative treatment, thus allowing time to perform more detailed non-interventional imaging (e.g., spiral computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP]) to determine the underlying cause and level of biliary obstruction. Those with cholangitis who do not respond to conservative therapy will require urgent biliary decompression. In patients with choledocholithiasis, endoscopic drainage is now the treatment of choice or, if this fails, transhepatic biliary decompression is a useful alternative. Various endoscopic options are available for managing choledocholithiasis, ranging from endoscopic papillotomy (EP) and extraction of stones, to the placement of a biliary drainage system. In patients who respond to antibiotic therapy, EP with stone extraction is preferred, while in those with ongoing sepsis and multiple large stones, the placement of a stent with or without an EP is the safest option. Transhepatic biliary drainage is now reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones. Surgical biliary decompression is seldom required in the emergency setting, but still plays an important role in the definitive treatment of the underlying cause.

PMID 14714159  J Hepatobiliary Pancreat Surg. 2003;10(6):406-14. doi: ・・・
著者: Masamichi Yokoe, Tadahiro Takada, Toshihiko Mayumi, Masahiro Yoshida, Hiroshi Hasegawa, Shinji Norimizu, Katsumi Hayashi, Shuichiro Umemura, Etsuro Orito
雑誌名: J Hepatobiliary Pancreat Sci. 2011 Mar;18(2):250-7. doi: 10.1007/s00534-010-0338-5.
Abstract/Text PURPOSE: Three years have passed since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis, and we believe that the time has come to assess their validity.
METHODS: In this study, we validated the diagnostic accuracy of these criteria in 74 patients with an initial diagnosis of acute cholangitis and 81 patients with an initial diagnosis of acute cholecystitis. We also statistically compared the accuracy of the diagnosis made based on the Tokyo Guidelines with that based on the presence of Charcot's triad for acute cholangitis and Murphy's sign for acute cholecystitis with use of the sign test to assess differences.
RESULTS: The results revealed that the diagnostic sensitivity and specificity of the Tokyo Guidelines for suspected or definitive acute cholangitis were 72.1 and 38.5%, respectively, and the corresponding values for definitive cholangitis alone were 63.9 and 69.2%, respectively. For definitive acute cholecystitis, the diagnostic sensitivity and specificity of the Tokyo Guidelines were 84.9 and 50.0%, respectively. The accuracy of diagnosis based on the Tokyo Guidelines was significantly higher than that based on the presence of Charcot's triad (acute cholangitis, p < 0.001 by the sign test) or Murphy's sign (acute cholecystitis, p < 0.001 by the sign test).
CONCLUSIONS: It was therefore concluded that the Tokyo Guidelines should be used more widely for the diagnosis of acute cholangitis and cholecystitis in the twenty-first century. Hereafter, various efforts should be made to improve the sensitivity and specificity of the diagnostic criterion of the Tokyo Guidelines.

PMID 21042814  J Hepatobiliary Pancreat Sci. 2011 Mar;18(2):250-7. doi・・・
著者: A Csendes, J C Diaz, P Burdiles, F Maluenda, E Morales
雑誌名: Br J Surg. 1992 Jul;79(7):655-8.
Abstract/Text A prospective study was performed in 1282 patients with common bile duct stones to determine the clinical and laboratory parameters that could predict cholangitis, and the factors associated with greater severity of cholangitis. Patients were divided into two groups, with or without acute cholangitis, depending on the macroscopic appearance of bile aspirated from the common bile duct during surgery. Acute cholangitis was diagnosed when the aspirated fluid was turbid or clearly pus; the typical Charcot's triad was present in only 22 per cent of patients with acute cholangitis. Several clinical and laboratory parameters were significantly more common in these patients and, depending on their number, the probability of acute cholangitis increased significantly. The operative mortality rate was 1.2 per cent for patients without cholangitis and 11.9 per cent for patients with cholangitis. Depending on the number of factors present, patients with cholangitis were divided into three groups: mild acute cholangitis without mortality; moderate acute cholangitis with a mortality rate of 5.6 per cent; and severe acute cholangitis with a mortality rate of 27.5 per cent. The present classification allows the group of patients needing prompt endoscopic or surgical drainage to be identified.

PMID 1643478  Br J Surg. 1992 Jul;79(7):655-8.
著者: J F Gigot, T Leese, T Dereme, J Coutinho, D Castaing, H Bismuth
雑誌名: Ann Surg. 1989 Apr;209(4):435-8.
Abstract/Text In order to identify risk factors in patients with acute cholangitis, 140 clinical, biochemical, etiologic, and pathologic variables of 449 attacks of acute cholangitis seen in one center over a 20-year period were analyzed. Simple regression revealed 24 factors with prognostic significance, but multivariate analysis detected only seven factors with independent significance in predicting mortality (acute renal failure, cholangitis associated with liver abscesses or liver cirrhosis, cholangitis secondary to high malignant biliary strictures or after percutaneous transhepatic cholangiography, female gender, and age). When the presence of each of these factors is weighted proportional to its coefficient of regression, patients with cholangitis could be scored on a scale of 0-27. A score of seven was clinically the most useful cut off--388 attacks of cholangitis associated with a score of less than 7 had a mortality rate of only 1.8%, whereas 61 attacks associated with a score greater than or equal to 7 had a mortality rate of 49%. The value of this scoring system needs to be confirmed in prospective studies, but it may prove useful, for example, in selecting a group of high-risk patients for urgent biliary decompression in an attempt to reduce the mortality associated with this pathology.

PMID 2930289  Ann Surg. 1989 Apr;209(4):435-8.
著者: J P Neoptolemos, D L Carr-Locke, T Leese, D James
雑誌名: Br J Surg. 1987 Dec;74(12):1103-6.
Abstract/Text Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.

PMID 3427354  Br J Surg. 1987 Dec;74(12):1103-6.
著者: C L Rosen, D F Brown, Y Chang, C Moore, N J Averill, L J Arkoff, C J McCabe, R E Wolfe
雑誌名: Am J Emerg Med. 2001 Jan;19(1):32-6. doi: 10.1053/ajem.2001.20028.
Abstract/Text This article investigates the use of bedside abdominal ultrasonography (BAU) performed by emergency physicians (EPs) to screen patients for cholelithiasis and cholecystitis. In this prospective study EPs performed BAU on 116 patients. Agreement between BAU and formal abdominal ultrasound (FUS) performed in the radiology department for detecting cholelithiasis and cholecystitis was determined using Kappa statistics. Test characteristics of BAU for detecting cholelithiasis and acute cholecystitis were calculated. Agreement between BAU and FUS was 0.71 for cholelithiasis and 0.46 for acute cholecystitis. Test characteristics of BAU for cholelithiasis were sensitivity 92%, specificity 78%, positive predictive value (PPV) 86%, negative predictive value (NPV) 88%. Test characteristics of BAU for acute cholecystitis compared with clinical follow-up were sensitivity 91%, specificity 66%, PPV 70%, NPV 90%. BAU may be used to exclude cholelithiasis and is sensitive for cholecystitis. However, when EPs with limited experience identify cholecystitis a confirmatory test is warranted before cholecystectomy.

PMID 11146014  Am J Emerg Med. 2001 Jan;19(1):32-6. doi: 10.1053/ajem.・・・
著者: J L Kendall, R J Shimp
雑誌名: J Emerg Med. 2001 Jul;21(1):7-13.
Abstract/Text The objectives of this study were to determine the accuracy of Emergency Physicians (EP) performing focused right upper quadrant (RUQ) ultrasound, to quantify how sonographic experience affects accuracy for gallbladder pathology, and to establish the time needed to complete a focused RUQ ultrasound. A convenience sample of patients with suspected gallbladder disease received a focused RUQ ultrasound by an EP. Sonographic findings, number of previous RUQ ultrasounds performed, and time for examination completion were recorded. Each patient then had a formal RUQ ultrasound by a sonographer blinded to the focused RUQ ultrasound results. Focused RUQ and formal ultrasound findings were compared, with the exception of the sonographic Murphy sign, which was compared to pathology reports. One hundred nine patients were enrolled. Fifty-one had gallstones. Forty-nine were detected by EPs, yielding a sensitivity of 96% [95% confidence interval (CI).87-.99]. Of the 58 patients without gallstones, 51 were correctly diagnosed by EPs (specificity = 88%, 95% CI.77-.95). The sonographic Murphy sign was present during 54 emergency examinations, but in only 24 formal studies. When compared to pathology reports, the emergency sonographic Murphy sign had a sensitivity of 75% compared to the formal ultrasound sensitivity of 45% for acute cholecystitis. EPs were less accurate for other sonographic findings, and level of experience had little effect on sensitivity or specificity for detecting gallstones. Eighty-three percent of emergency studies were completed in less than 10 min. Gallstones are accurately detected by EPs in a timely fashion. Additionally, compared to the radiologist's interpretation, the EP-detected sonographic Murphy sign was more sensitive for diagnosing acute cholecystitis.

PMID 11399381  J Emerg Med. 2001 Jul;21(1):7-13.
著者: Susanna C Spence, Davis Teichgraeber, Chitra Chandrasekhar
雑誌名: J Ultrasound Med. 2009 Apr;28(4):479-96.
Abstract/Text OBJECTIVE: The purpose of this presentation is to review the sonographic spectrum of disease entities evaluated by right upper quadrant (RUQ) sonography on an emergent basis.
METHODS: Right upper quadrant sonography was performed on an emergent basis in patients who came to the emergency department with signs and symptoms suspicious for or simulating acute cholecystitis or diseases of the liver and biliary tree.
RESULTS: A wide gamut of acute and chronic cholecystitis and diseases of the liver and biliary tree were visualized on RUQ sonography. Several other entities in addition to hepatic and biliary disease were also suspected on sonography and further evaluated by computed tomography.
CONCLUSIONS: Right upper quadrant sonography is the first line of imaging in patients with signs and symptoms of hepatic, gallbladder, or biliary disease as well as RUQ pain. Patient triage or additional imaging may be obtained on the basis of emergent RUQ sonographic findings.

PMID 19321676  J Ultrasound Med. 2009 Apr;28(4):479-96.
著者: Fumihiko Miura, Kohji Okamoto, Tadahiro Takada, Steven M Strasberg, Horacio J Asbun, Henry A Pitt, Harumi Gomi, Joseph S Solomkin, David Schlossberg, Ho-Seong Han, Myung-Hwan Kim, Tsann-Long Hwang, Miin-Fu Chen, Wayne Shih-Wei Huang, Seiki Kiriyama, Takao Itoi, O James Garden, Kui-Hin Liau, Akihiko Horiguchi, Keng-Hao Liu, Cheng-Hsi Su, Dirk J Gouma, Giulio Belli, Christos Dervenis, Palepu Jagannath, Angus C W Chan, Wan Yee Lau, Itaru Endo, Kenji Suzuki, Yoo-Seok Yoon, Eduardo de Santibañes, Mariano Eduardo Giménez, Eduard Jonas, Harjit Singh, Goro Honda, Koji Asai, Yasuhisa Mori, Keita Wada, Ryota Higuchi, Manabu Watanabe, Toshiki Rikiyama, Naohiro Sata, Nobuyasu Kano, Akiko Umezawa, Shuntaro Mukai, Hiromi Tokumura, Jiro Hata, Kazuto Kozaka, Yukio Iwashita, Taizo Hibi, Masamichi Yokoe, Taizo Kimura, Seigo Kitano, Masafumi Inomata, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40. doi: 10.1002/jhbp.509. Epub 2018 Jan 8.
Abstract/Text The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28941329  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40. doi・・・
著者: A Laokpessi, P Bouillet, D Sautereau, F Cessot, J C Desport, A Le Sidaner, B Pillegand
雑誌名: Am J Gastroenterol. 2001 Aug;96(8):2354-9. doi: 10.1111/j.1572-0241.2001.04045.x.
Abstract/Text OBJECTIVE: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis.
METHODS: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi.
RESULTS: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The false-negative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques.
CONCLUSION: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.

PMID 11513174  Am J Gastroenterol. 2001 Aug;96(8):2354-9. doi: 10.1111・・・
著者: D Lomanto, P Pavone, A Laghi, V Panebianco, P Mazzocchi, F Fiocca, E Lezoche, R Passariello, V Speranza
雑誌名: Am J Surg. 1997 Jul;174(1):33-8. doi: 10.1016/S0002-9610(97)00022-6.
Abstract/Text BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases.
PATIENTS AND METHODS: One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases.
RESULTS: In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films.
CONCLUSIONS: MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

PMID 9240949  Am J Surg. 1997 Jul;174(1):33-8. doi: 10.1016/S0002-961・・・
著者: S H Zidi, F Prat, O Le Guen, Y Rondeau, L Rocher, J Fritsch, A D Choury, G Pelletier
雑誌名: Gut. 1999 Jan;44(1):118-22.
Abstract/Text BACKGROUND: Magnetic resonance cholangiography (MRC) is a new technique for non-invasive imaging of the biliary tract.
AIM: To assess the results of MRC in patients with suspected bile duct stones as compared with those obtained with reference imaging methods.
PATIENTS/METHODS: 70 patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median 75) with suspected bile duct stones were included (cholangitis, 33; pancreatitis, three; suspected post-cholecystectomy choledocholithiasis, nine; cholestasis, six; stones suspected on ultrasound or computed tomography scan, 19). MR cholangiograms with two dimensional turbo spin echo sequences were acquired. Endoscopic retrograde cholangiography with or without sphincterotomy (n = 63), endosonography (n = 5), or intraoperative cholangiography (n = 2) were the reference imaging techniques used for the study and were performed within 12 hours of MRC. Radiologists were blinded to the results of endoscopic retrograde cholangiography and previous investigations.
RESULTS: 49 patients (70%) had bile duct stones on reference imaging (common bile duct, 44, six of which impacted in the papilla; intrahepatic, four; cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smaller than 6 mm. MRC diagnostic accuracy for bile duct lithiasis was: sensitivity, 57.1%; specificity, 100%; positive predictive value, 100%; negative predictive value, 50%.
CONCLUSIONS: Stones smaller than 6 mm are still often missed by MRC when standard equipment is used. The general introduction of new technical improvements is needed before this method can be considered reliable for the diagnosis of bile duct stones.

PMID 9862837  Gut. 1999 Jan;44(1):118-22.
著者: K D Lillemoe
雑誌名: Am Surg. 2000 Feb;66(2):138-44.
Abstract/Text Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.

PMID 10695743  Am Surg. 2000 Feb;66(2):138-44.
著者: W Sievert, N B Vakil
雑誌名: Gastroenterol Clin North Am. 1988 Jun;17(2):245-64.
Abstract/Text The traditional approach to urgent therapy of biliary tract disease has undergone significant change. Technologic advances now permit a nonoperative approach to acute cholangitis, acute gallstone pancreatitis and hemobilia. Acute cholecystitis continues to be treated surgically in most cases. The clinical use of such nonoperative therapy has been guided mainly by retrospective data. The precise indications and optimal timing for endoscopic and radiologic therapy and their relationship to traditional surgical therapy remains to be defined by careful prospective evaluation.

PMID 3049344  Gastroenterol Clin North Am. 1988 Jun;17(2):245-64.
著者: S C Kadakia
雑誌名: Med Clin North Am. 1993 Sep;77(5):1015-36.
Abstract/Text Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

PMID 8371614  Med Clin North Am. 1993 Sep;77(5):1015-36.
著者: L H Hanau, N H Steigbigel
雑誌名: Infect Dis Clin North Am. 2000 Sep;14(3):521-46.
Abstract/Text Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

PMID 10987108  Infect Dis Clin North Am. 2000 Sep;14(3):521-46.
著者: S A Cohen, J H Siegel
雑誌名: Crit Care Clin. 1995 Apr;11(2):273-94.
Abstract/Text The application of therapeutic ERCP and interventional radiology has significantly altered the treatment of biliary tract emergencies. Although surgery is the principal treatment for acute cholecystitis, nonoperative alternatives exist for high-risk patients. New, prospective, randomized trials have demonstrated that endoscopic management of severe cholangitis is superior to surgery, and that endoscopic sphincterotomy and stone extraction are superior to conservative treatment in severe gallstone pancreatitis. ERCP allows nonoperative management of postoperative bile leaks as well.

PMID 7788532  Crit Care Clin. 1995 Apr;11(2):273-94.
著者: Shuntaro Mukai, Takao Itoi, Todd H Baron, Tadahiro Takada, Steven M Strasberg, Henry A Pitt, Tomohiko Ukai, Satoru Shikata, Anthony Yuen Bun Teoh, Myung-Hwan Kim, Seiki Kiriyama, Yasuhisa Mori, Fumihiko Miura, Miin-Fu Chen, Wan Yee Lau, Keita Wada, Avinash Nivritti Supe, Mariano Eduardo Giménez, Masahiro Yoshida, Toshihiko Mayumi, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2017 Oct;24(10):537-549. doi: 10.1002/jhbp.496. Epub 2017 Oct 5.
Abstract/Text The Tokyo Guidelines 2013 (TG13) include new topics in the biliary drainage section. From these topics, we describe the indications and new techniques of biliary drainage for acute cholangitis with videos. Recently, many novel studies and case series have been published across the world, thus TG13 need to be updated regarding the indications and selection of biliary drainage based on published data. Herein, we describe the latest updated TG13 on biliary drainage in acute cholangitis with meta-analysis. The present study showed that endoscopic transpapillary biliary drainage regardless of the use of nasobiliary drainage or biliary stenting, should be selected as the first-line therapy for acute cholangitis. In acute cholangitis, endoscopic sphincterotomy (EST) is not routinely required for biliary drainage alone because of the concern of post-EST bleeding. In case of concomitant bile duct stones, stone removal following EST at a single session may be considered in patients with mild or moderate acute cholangitis except in patients under anticoagulant therapy or with coagulopathy. We recommend the removal of difficult stones at two sessions after drainage in patients with a large stone or multiple stones. In patients with potential coagulopathy, endoscopic papillary dilation can be a better technique than EST for stone removal. Presently, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is used as the first-line therapy for biliary drainage in patients with surgically altered anatomy where BE-ERCP expertise is present. However, the technical success rate is not always high. Thus, several studies have revealed that endoscopic ultrasonography-guided biliary drainage (EUS-BD) can be one of the second-line therapies in failed BE-ERCP as an alternative to percutaneous transhepatic biliary drainage where EUS-BD expertise is present.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28834389  J Hepatobiliary Pancreat Sci. 2017 Oct;24(10):537-549. ・・・
著者: L H Hanau, N H Steigbigel
雑誌名: Curr Clin Top Infect Dis. 1995;15:153-78.
Abstract/Text
PMID 7546366  Curr Clin Top Infect Dis. 1995;15:153-78.
著者: J F Westphal, J M Brogard
雑誌名: Drugs. 1999 Jan;57(1):81-91.
Abstract/Text Initial therapy of acute cholecystitis and cholangitis is directed towards general support of the patient, including fluid and electrolyte replacement, correction of metabolic imbalances and antibacterial therapy. Factors affecting the efficacy of antibacterial therapy include the activity of the agent against the common biliary tract pathogens and pharmacokinetic properties such as tissue distribution and the ratio of concentration in both bile and serum to the minimum inhibitory concentration for the expected micro-organism. Antimicrobial therapy is usually empirical. Initial therapy should cover the Enterobacteriaceae, in particular Escherichia coli. Activity against enterococci is not required since their pathogenicity in biliary tract infections remains unclear. Coverage of anaerobes, in particular Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, in the elderly and in patients in serious clinical condition. In patients with acute cholecystitis or cholangitis of moderate clinical severity, monotherapy with a ureidopenicillin--mezlocillin or piperacillin--is at least as effective as the combination of ampicillin plus aminoglycoside. In severely ill patients with septicaemia, an antibacterial combination is preferable. Therapy with aminoglycosides, mostly for Pseudomonas aeruginosa-related infections, should not exceed a few days because the risk of nephrotoxicity seems to be increased during cholestasis. Relief of biliary obstruction is mandatory, even if there is clinical improvement with conservative therapy, because cholangitis is most likely to recur with continued obstruction. Emergency invasive therapy is reserved for patients who fail to show a clinical response to antibacterial therapy within the first 36 to 48 hours or for those who deteriorate after an initial clinical improvement. Immediate surgery is indicated for gangrenous cholecystitis and perforation with peritonitis. Long-term administration of antibacterials is required for recurrent cholangitis, as seen in bile duct-bowel anastomosis. Oral cotrimoxazole (trimethoprim/sulfamethoxazole) is the preferred agent. Wound infection rates after biliary tract surgery can be significantly reduced by preoperative administration of prophylactic antibacterials. Newer generation beta-lactams have not proven to be of greater benefit than older agents such as cefuroxime or cefazolin. Antibacterial prophylaxis before endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice, since the risk of infectious complications seems to be strongly associated with this clinical condition. Failure to achieve full biliary drainage is the most important factor in predicting septicaemia, and prophylaxis should be prolonged until the bile duct is unobstructed. Piperacillin, cefazolin, cefuroxime, cefotaxime and ciprofloxacin are effective for this indication.

PMID 9951953  Drugs. 1999 Jan;57(1):81-91.
著者: Harumi Gomi, Joseph S Solomkin, David Schlossberg, Kohji Okamoto, Tadahiro Takada, Steven M Strasberg, Tomohiko Ukai, Itaru Endo, Yukio Iwashita, Taizo Hibi, Henry A Pitt, Naohisa Matsunaga, Yoriyuki Takamori, Akiko Umezawa, Koji Asai, Kenji Suzuki, Ho-Seong Han, Tsann-Long Hwang, Yasuhisa Mori, Yoo-Seok Yoon, Wayne Shih-Wei Huang, Giulio Belli, Christos Dervenis, Masamichi Yokoe, Seiki Kiriyama, Takao Itoi, Palepu Jagannath, O James Garden, Fumihiko Miura, Eduardo de Santibañes, Satoru Shikata, Yoshinori Noguchi, Keita Wada, Goro Honda, Avinash Nivritti Supe, Masahiro Yoshida, Toshihiko Mayumi, Dirk J Gouma, Daniel J Deziel, Kui-Hin Liau, Miin-Fu Chen, Keng-Hao Liu, Cheng-Hsi Su, Angus C W Chan, Dong-Sup Yoon, In-Seok Choi, Eduard Jonas, Xiao-Ping Chen, Sheung Tat Fan, Chen-Guo Ker, Mariano Eduardo Giménez, Seigo Kitano, Masafumi Inomata, Shuntaro Mukai, Ryota Higuchi, Koichi Hirata, Kazuo Inui, Yoshinobu Sumiyama, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518. Epub 2018 Jan 9.
Abstract/Text Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29090866  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16. doi:・・・
著者: A Csendes, P Burdiles, F Maluenda, J C Diaz, P Csendes, N Mitru
雑誌名: Arch Surg. 1996 Apr;131(4):389-94.
Abstract/Text OBJECTIVES: To determine the simultaneous prevalence of bacteria in bile from the gallbladder and common bile duct and to determine the influence of the number of stones present on bacteriologic findings.
METHODS: A prospective study was performed in 467 subjects divided into seven groups: 42 control subjects with normal biliary tracts, 221 patients with symptomatic gallstone disease, 12 patients with hydropic gallbladder, 52 patients with acute cholecystitis, 67 patients with common bile duct stones without cholangitis, 49 patients with common bile duct stones and acute cholangitis, and 24 patients with previous cholecystectomy and common bile duct stones. In all except controls, bile samples from the gallbladder and common bile duct were taken simultaneously for aerobic and anaerobic cultures.
RESULTS: Control subjects had no bacteria in gallbladder bile. Patients with gallstones, acute cholecystitis, and hydropic gallbladder had similar rates of positive cultures in the gallbladder and common bile duct, ranging from 22% to 46%, but the rate was significantly higher in patients with common bile duct stones without cholangitis (58.2%). Patients with cholangitis or previous cholecystectomy had a high rate of positive cultures of common duct bile (93% to 100%). Age greater than 60 years had a significant influence on the rate of positive bile cultures. There was no relationship between the number of stones in the gallbladder or common bile duct and the percentage of positive cultures. In 98% of the patients, the same bacteria were isolated from gallbladder and common duct bile.
CONCLUSIONS: In normal subjects, no bacteria were present in the biliary tract. Among patients with common bile duct stones, there was an increasing percentage of positive cultures according to the severity of the disease. Age had an important influence, but sex and the number of common bile duct stones had no influence on positive cultures.

PMID 8615724  Arch Surg. 1996 Apr;131(4):389-94.
著者: A Csendes, N Mitru, F Maluenda, J C Diaz, P Burdiles, P Csendes, E Pinones
雑誌名: Hepatogastroenterology. 1996 Jul-Aug;43(10):800-6.
Abstract/Text BACKGROUND/AIMS: The number of colonies of bacteria and the number of pyocites present per ml of choledochal bile was studied.
PATIENTS AND METHODS: There were 42 controls, 100 patients with symptomatic gallstones, 42 patients with common duct stones without cholangitis and 24 patients with common duct stones and acute cholangitis.
RESULTS: Control subjects had no bacteria present at gallbladder bile. Only 3% of patients with gallstones had more than 10(5) colonies per ml which increased to 36% in patients with common duct stones without cholangitis and to 84% among patients with acute cholangitis (p < 0.001). There were more polybacterial flora among patients with acute cholangitis and anaerobic bacteria were not seen in patients with gallstones. Patients with acute cholangitis had significantly more pyocites present at choledochal bile.
CONCLUSION: There is a direct correlation between the number of colonies present per ml of choledochal bile and the severity of biliary tract disease. Patients with acute cholangitis had significantly more pyocites present at choledochal bile compared to gallstones or patients with CBD stones without cholangitis.

PMID 8884293  Hepatogastroenterology. 1996 Jul-Aug;43(10):800-6.
著者: C Marne, R Pallarés, R Martín, A Sitges-Serra
雑誌名: Eur J Clin Microbiol. 1986 Feb;5(1):35-9.
Abstract/Text The incidence of anaerobic bacteria in bile, and the relationship between bacterial species isolated from the bile and the clinical characteristics of disease in these patients was studied. One hundred and twenty-five bile specimens obtained during surgery from the same number of patients were cultured aerobically and anaerobically. Seventy patients (56%) had positive cultures and in 30% of the patients with positive cultures anaerobic bacteria were recovered, usually together with aerobic bacteria. Members of the Bacteroides fragilis group were the most frequently isolated anaerobic organisms. There was a high rate of isolation of anaerobic bacteria from bile in patients with gangrenous cholecystitis (72%) or acute cholangitis (50%). Administration of antibiotics effective against anaerobic bacteria should be considered when treating these diseases.

PMID 2870920  Eur J Clin Microbiol. 1986 Feb;5(1):35-9.
著者: B E Claesson, D E Holmlund, T W Mätzsch
雑誌名: Surg Gynecol Obstet. 1986 Jun;162(6):531-5.
Abstract/Text The microflora of the bile and wall of the gallbladder was prospectively investigated in 104 nonselected consecutive patients treated with early cholecystectomy for acute cholecystitis after an average hospital stay of 1.8 days. The chief purpose was to relate the findings of cultures to duration of the illness. Special attention was paid to anaerobic isolation techniques. The cultures yielded 107 strains, representing 36 species, with overall agreement between four different sampling procedures. Aerobic gram-negative rods predominated, followed by streptococci and anaerobes (48, 31 and 15 per cent, respectively). The incidence of positive culture results (always greater than or equal to 10(6) colon forming units per milliliter) was 81 per cent among the patients who underwent operation within two days from the onset of symptoms and 50 to 65 per cent after longer preoperative intervals. The shorter interval was significantly more often associated with growth solely of anaerobes (p = 0.03). Postoperative sepsis was caused by biliary bacteria and not related to preoperative duration of illness. Appropriate perioperative antibiotic coverage significantly reduced sepsis--3 versus 20 per cent (p = 0.05).

PMID 3715685  Surg Gynecol Obstet. 1986 Jun;162(6):531-5.
著者: Joseph S Solomkin, John E Mazuski, John S Bradley, Keith A Rodvold, Ellie J C Goldstein, Ellen J Baron, Patrick J O'Neill, Anthony W Chow, E Patchen Dellinger, Soumitra R Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K May, Avery B Nathens, Robert G Sawyer, John G Bartlett
雑誌名: Clin Infect Dis. 2010 Jan 15;50(2):133-64. doi: 10.1086/649554.
Abstract/Text Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

PMID 20034345  Clin Infect Dis. 2010 Jan 15;50(2):133-64. doi: 10.1086・・・
著者: H A Pitt, R G Postier, J L Cameron
雑誌名: Surgery. 1983 Sep;94(3):447-52.
Abstract/Text During a 30-month period 73 patients underwent operation for choledocholithiasis. Thirty-three of these patients (45%) had cholangitis preoperatively. When compared to patients with common duct stones who had no preoperative cholangitis, patients with cholangitis were older (P less than 0.001), more likely to present with jaundice (P less than 0.01) and leukocytosis (P less than 0.01), and more likely to have retained or primary common duct stones (P less than 0.01). Cholangitis patients were also more likely to have bactibilia (P less than 0.025), and anaerobes were isolated from the bile of 27% of these patients (P less than 0.01). Twenty-nine of 33 cholangitis patients (88%) received a minimum of 4 days of broad-spectrum antibiotics including an aminoglycoside prior to operation (P less than 0.01). Despite these clear differences, patients with preoperative cholangitis were not more likely to develop infective sequelae or biliary complications. However, cholangitis patients were much more likely (P less than 0.001) to develop an increase in serum creatinine (33% versus 3%) which, in turn, contributed to a longer (P less than 0.01) postoperative hospitalization. Since therapy with aminoglycosides may have contributed to postoperative morbidity and prolonged hospital stay, aminoglycosides should be reserved only for patients with the most severe cholangitis and should be used with great caution.

PMID 6612580  Surgery. 1983 Sep;94(3):447-52.
著者: F Maluenda, A Csendes, P Burdiles, J Diaz
雑誌名: Hepatogastroenterology. 1989 Jun;36(3):132-5.
Abstract/Text Acute suppurative cholangitis is a serious complication in extrahepatic biliary tract obstruction. Bacteriological studies have shown that in these patients the bile cultures usually present several kinds of bacteria, especially Gram-negative aerobic bacteria such as E. coli and Klebsiella sp. The mortality rate in our patients with common bile duct stones and acute suppurative cholangitis is enhanced 5- to 10-fold. The aim of the present study was to analyse the bacterial properties of choledochal bile in a large number of patients with common bile duct stones, with or without acute suppurative cholangitis, and to determine the sensitivity of the isolated bacteria to several antibiotics used in clinical practice. The greatest sensitivity of the bacteria isolated from the common bile duct was seen for aminoglycosides (gentamicin and amikacin) and for cephalosporins, especially of the third generation (cefotaxime, ceftazidime, ceftriaxone and cefoperazone). Ampicillin showed a low sensitivity rate. The appropriate selection of the antibiotics used in acute suppurative cholangitis depends not only on the concentration of the antibiotic in the bile; a high plasma concentration is even more important to control the septic manifestations. A high excretion to the bile can affect the intestinal flora, leading to diarrhea (e. g. with cefoperazone). Ampicillin has been giving contradictory results in respect of bile and plasma concentrations. Gentamicin attains 30-40% of the plasma concentration in the bile, but persists for as long as 8 hours with excellent sensitivity and clinical efficacy. Amikacin reaches 44% of the plasma concentration with a very high sensitivity (96%).(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 2502489  Hepatogastroenterology. 1989 Jun;36(3):132-5.
著者: E C Lai, F P Mok, E S Tan, C M Lo, S T Fan, K T You, J Wong
雑誌名: N Engl J Med. 1992 Jun 11;326(24):1582-6. doi: 10.1056/NEJM199206113262401.
Abstract/Text BACKGROUND: Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Because recent results suggested that emergency endoscopic drainage could improve the outcome of such patients, we undertook a prospective study to determine the role of this procedure as initial treatment.
METHODS: During a 43-month period, 82 patients with severe acute cholangitis due to choledocholithiasis were randomly assigned to undergo surgical decompression of the biliary tract (41 patients) or endoscopic biliary drainage (41 patients), followed by definitive treatment. Hospital mortality was analyzed with respect to the use of endoscopic biliary drainage and other clinical and laboratory findings. Prognostic determinants were studied by linear discriminant analysis.
RESULTS: Complications related to biliary tract decompression and subsequent definitive treatment developed in 14 patients treated with endoscopic biliary drainage and 27 treated with surgery (34 vs. 66 percent, P greater than 0.05). The time required for normalization of temperature and stabilization of blood pressure was similar in the two groups, but more patients in the surgery group required ventilatory support. The hospital mortality rate was significantly lower for the patients who underwent endoscopy (4 deaths) than for those treated surgically (13 deaths) (10 vs. 32 percent, P less than 0.03). The presence of concomitant medical problems, a low platelet count, a high serum urea nitrogen concentration, and a low serum albumin concentration before biliary decompression were the other independent determinants of mortality in both groups.
CONCLUSIONS: Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.

PMID 1584258  N Engl J Med. 1992 Jun 11;326(24):1582-6. doi: 10.1056/・・・
著者: Toshio Tsuyuguchi, Tadahiro Takada, Yoshifumi Kawarada, Yuji Nimura, Keita Wada, Masato Nagino, Toshihiko Mayumi, Masahiro Yoshida, Fumihiko Miura, Atsushi Tanaka, Yuichi Yamashita, Masahiko Hirota, Koichi Hirata, Hideki Yasuda, Yasutoshi Kimura, Steven Strasberg, Henry Pitt, Markus W Büchler, Horst Neuhaus, Jacques Belghiti, Eduardo de Santibanes, Sheung-Tat Fan, Kui-Hin Liau, Vibul Sachakul
雑誌名: J Hepatobiliary Pancreat Surg. 2007;14(1):35-45. doi: 10.1007/s00534-006-1154-9. Epub 2007 Jan 30.
Abstract/Text Biliary decompression and drainage done in a timely manner is the cornerstone of acute cholangitis treatment. The mortality rate of acute cholangitis was extremely high when no interventional procedures, other than open drainage, were available. At present, endoscopic drainage is the procedure of first choice, in view of its safety and effectiveness. In patients with severe (grade III) disease, defined according to the severity assessment criteria in the Guidelines, biliary drainage should be done promptly with respiration management, while patients with moderate (grade II) disease also need to undergo drainage promptly with close monitoring of their responses to the primary care. For endoscopic drainage, endoscopic nasobiliary drainage (ENBD) or stent placement procedures are performed. Randomized controlled trials (RCTs) have reported no difference in the drainage effect of these two procedures, but case-series studies have indicated the frequent occurrence of hemorrhage associated with endoscopic sphincterotomy (EST), and complications such as pancreatitis. Although the usefulness of percutaneous transhepatic drainage is supported by the case-series studies, its lower success rate and higher complication rates makes it a second-option procedure.

PMID 17252295  J Hepatobiliary Pancreat Surg. 2007;14(1):35-45. doi: 1・・・

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