Background: Acute cholangitis (AC) in children is a rare but life-threatening infection. Symptoms vary from mild to severe disease. There are no local published data on pediatric AC. Objective: To determine the clinical, biochemical, ultrasonographic, microbiologic features, and treatment outcome of pediatric patients with definite AC. Methodology: Cross-sectional study using medical records of pediatric patients diagnosed with definite AC based on the Modified Tokyo Guidelines of 2018 admitted from January 2016 to June 2021. Results: Twenty-seven patients aged 0 to 18 years old (10.06 + 7.34), predominantly male (51.85%) were included. Choledocholithiasis (22%) and post-Kasai biliary atresia (22%) were the common underlying biliary conditions. Fever (88.89%) was the most frequent presenting symptom. Majority were classified as moderate AC (40.74%). Leukocytosis (mean 16×109/L), elevated inflammatory markers (93.33% with CRP >12mg/L and 100% with serum procalcitonin >0.25ng/mL), hyperbilirubinemia (total bilirubin 192.54±126.87umol/L) and elevated alanine transferases (mean 59 IU/L) were noted. Twenty-one out of 27 cases (87%) had a negative blood culture. Only 4 patients underwent bile culture, of which two (50%) grew Klebsiella pneumoniae resistant to empiric antibiotics. Dilated biliary ducts were observed on abdominal ultrasound in 92.59% of patients. Ampicillin-sulbactam (29.63%) was the most commonly utilized antibiotic. Discharge rate was high (88.89%). Conclusions AC affects all pediatric age groups but clinical presentations vary. Drug resistant organisms are a significant concern but despite this, favorable outcomes have been documented.
Cholangitis ; Child ; Choledocholithiasis

Objective: The study was performed to assess and compare the effect of early (≤ 72 hours) and late (>72 hours) laparoscopic cholecystectomy after Endoscopic retrograde cholangio pancreatography (ERCP) in terms of duration of operation, conversion to open cholecystectomy, intraoperative complicating factors, duration of hospital stay from the date of ERCP, hospital expenses, and presence of postoperative complications. Methods: This is a retrospective study from 2010 up to July 2019. Outcomes (duration of operation, rate of conversion, intraoperative complicating factors, length of hospital stay, hospital expenses and post-operative complications) were compared between patients who had ERCP then cholecystectomy within 72 hours (Early Group) and those who had ERCP then cholecystectomy after more than 72 hours (Late Group). Results: A total of 19 patients were included in this study. There were 10 patients in the Early Group and 9 in the Late Group. Early laparoscopic cholecystectomy after ERCP had a shorter statistically significant duration of hospital. Shorter operative time, fewer intraoperative complicating factors, no conversion to open cholecystectomy, cheaper hospital expenses and no post-operative complications were also noted in the Early Group as compared to the Late Group. Conclusion Early laparoscopic cholecystectomy is safe and results in a shorter hospital stay compared to late laparoscopic cholecystectomy.
Choledocholithiasis ; Cholecystolithiasis

Objective To evaluate the safety and effectiveness of laparoscopic common bile duct exploration in the treatment of common bile duct stones. Methods A retrospective analysis was conducted for 158 patients with cholecystolithiasis and choledocholithiasis admitted to the Number One Hospital of Zhangjiakou from January 2015 to December 2019.The patients were assigned into three groups according to the diameters of cystic duct and common bile duct,degrees of abdominal infection and tissue edema,and operation method.Group A(16 cases):laparoscopic cholecystectomy,transcystic choledochoscopic exploration for stone removal;Group B(94 cases):laparoscopic cholecystectomy,common bile duct incision exploration combined with choledochoscopy for stone removal,T tube drainage;Group C(48 cases):laparoscopic cholecystectomy,common bile duct incision exploration combined with choledochoscopy for stone removal,primary closure of the common bile duct.The operation time,residual rate of stones,and complication(bleeding,bile leakage,and wound infection) rate were compared between groups. Results The operation time of groups A,B,and C was(95.1±14.7),(102.2±18.1),(110.1±16.4) minutes,respectively,which showed no statistical difference between each other(F=0.020,P=0.887).One case in group A had residual stones,while no residual stone appeared in groups B and C.The overall stone clearance rate was 99.4% and the overall complication rate was 1.9%.There was no perioperative death. Conclusion It is generally safe and effective to carry out laparoscopic cholecystectomy and common bile duct exploration for stone removal in suitable populations.
Choledocholithiasis/surgery* ; Common Bile Duct/surgery* ; Gallstones/surgery* ; Humans ; Laparoscopy/methods* ; Retrospective Studies

Ampulla of Vater/pathology* ; Carcinoma/pathology* ; Common Bile Duct Neoplasms/surgery* ; Humans

OBJECTIVE: To distinguish the endoscopic and clinical features of ampullary polyps, to investigate the endoscopic cancer risk factors of ampullary polyps based on the compared differences of benign lesions and adenocarcinoma, and to assess the accuracy of forceps biopsy. METHODS: Authors retrospectively analyzed the data extracted from patients treated with endoscopic papillectomy (EP) from January 2009 to May 2019 in the Department of Gastroenterology, Peking University Third Hospital. Endoscopic pictures and pathology reports were reevaluated and analyzed. Differences between benign and cancer groups were conducted. RESULTS: In the study, 42 cases were involved, 35 to 83 years old, containing 83.3% older than 50 years old patients. The histological types were as follows, 2 for inflammatory polyps (4.8%), 1 for neuroendocrine tumor (2.4%), 1 for hyperplastic polyp (2.4%), 5 for grade Ⅰ adenoma (11.9%), 10 for grade Ⅱ adenoma (23.8%), 4 for grade Ⅲ adenoma (9.5%) and 19 for adenocarcinoma (45.2%), and 90.5% were adenoma or adenocarcinoma. The average age of benign group (inflammatory polyps and adenomas) was (56.7±9.2), which was significantly younger than that of adenocarcinoma group [(66.0±9.8), P=0.004]. Tumor diameter in adenocarcinoma group[(2.3±0.8) cm] was significantly larger than that in benign group[(1.6±0.6) cm, P=0.002]. Benign lesions only showed Yamada type Ⅰ(57.1%)and type Ⅱ(42.9%). The percentage of Yamada type Ⅰ (36.8%)and type Ⅱ(31.6%) in adenocarcinoma group was lower than that in benign group. Moreover, Yamada type Ⅲ (31.5%) was only found in the adenocarcinoma group. Significant differences were observed between the two groups in Yamada types (P=0.046). Most of the benign lesions had clear boundary(18/21, 85.7%). The percentage of clear boundary in adenocarcinoma group (2/19, 10.5%) was significantly lower than that in the benign group (P < 0.001). No significant differences were investigated in color (P=0.353) and surface (P=0.324) between benign and adenocarcinoma lesions. Pooling age, lesion diameter, Yamada type and clear boundary into Logistic regression analysis, only age (OR=1.186, 95%CI 1.025-1.373, P=0.022) and clear boundary (OR=66.218, 95%CI 3.421-1 281.840, P=0.006) were the independent cancer risk factors. Only 2 (10.5%) in the 19 cancer patients had positive biopsy results before EP. As compared with post-EP, 55.3% (21/38) biopsies were under-estimated, including 17 (17/19, 89.5%) adenocarcinomas and 4 (4/10, 40%) grade Ⅱ adenomas. CONCLUSION adenoma and adenocarcinoma were the major histological type of ampullary po-lyps. Age and unclear boundary were the independent risk factors of ampullary adenocarcinoma. Forceps biopsy was not enough for ampullary polyp differentiation.
Adult ; Aged ; Aged, 80 and over ; Biopsy ; Common Bile Duct Neoplasms/surgery* ; Humans ; Middle Aged ; Polyps ; Retrospective Studies ; Surgical Instruments ; Treatment Outcome

BACKGROUND/AIMS: The clinical impact of single-stage endoscopic stone extraction by endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy during the same hospitalization remains elusive. This study aimed to determine the efficacy and safety of single-stage ERCP and cholecystectomy during the same hospitalization in patients with cholangitis. METHODS: We retrospectively reviewed the medical records of 166 patients who underwent ERCP for mild to moderate cholangitis due to choledocholithiasis secondary to cholecystolithiasis from 2012 to 2016. RESULTS: Complete stone extraction was accomplished in 92% of patients (152/166) at the first ERCP. Among 152 patients who underwent complete stone extraction, cholecystectomy was scheduled for 119 patients (78%). Cholecystectomy was performed during the same hospitalization in 89% of patients (106/119). We compared two groups of patients: those who underwent cholecystectomy during the same hospitalization (n=106) and those who underwent cholecystectomy during a subsequent hospitalization (n=13). In the delayed group, cholecystectomy was performed about three months after the first ERCP. There were no significant differences between the groups in terms of operative time, rate of postoperative complications, and interval from cholecystectomy to discharge. CONCLUSIONS: Single-stage endoscopic stone extraction is recommended in patients with mild to moderate acute cholangitis due to choledocholithiasis. The combination of endoscopic stone extraction and cholecystectomy during the same hospitalization is safe and feasible.
Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Cholecystectomy ; Cholecystectomy, Laparoscopic ; Cholecystolithiasis ; Choledocholithiasis ; Hospitalization ; Humans ; Medical Records ; Operative Time ; Patient Outcome Assessment ; Postoperative Complications ; Retrospective Studies

Endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) have been performed all around the world over several decades for the treatment of common bile duct stone. EPBD using small dilation balloon catheter can preserve sphincter of Oddi function and reduce the recurrence rate of bile duct stone compared to endoscopic sphincterotomy (EST). EPBD is a procedure with low risk of bleeding, which is appropriate for patients with coagulopathy, hepatic cirrhosis, end-stage of renal disease, and surgically altered anatomy such as Billroth II gastrectomy and periampullary diverticulum. However, it has a higher risk of postprocedure pancreatitis than EST. EPLBD using large balloon catheter (12 mm or more of diameter) is proper for more than 10 mm of common bile duct stone. The advantages of EPLBD are reduced need for mechanical lithotripsy with decreased procedure time and radiation exposure time irrespective of the precedence of EST. EPLBD also requires fewer endoscopic retrograde cholangiopancreatography sessions and is more cost-effective. The incidence of post-procedure pancreatitis is lower in EPLBD than EST. If EPBD and EPLBD are done under the guidelines, these would be safe and effective and may be alternatives to EST for common bile duct stone.
Bile Ducts ; Catheters ; Cholangiopancreatography, Endoscopic Retrograde ; Choledocholithiasis ; Common Bile Duct ; Diverticulum ; Gastrectomy ; Gastroenterostomy ; Hemorrhage ; Humans ; Incidence ; Lithotripsy ; Liver Cirrhosis ; Pancreatitis ; Radiation Exposure ; Recurrence ; Sphincter of Oddi ; Sphincterotomy, Endoscopic

Endoscopic sphincterotomy is performed after selective cannulation to remove the gallstone. Endoscopic sphincterotomy can cause complications such as bleeding, perforation and pancreatitis. Various types of endoscopic sphincter incision method and current generators used for incisions have been developed to reduce the incidence of such complications and increase the success rate of the procedure. In addition, guidelines for the direction and extent of endoscopic sphincterotomy and incision technique are established. The method used for the removal of gallstones after the endoscopic sphincterotomy is a method using a balloon and/or a basket. This review introduces the technical methods of endoscopic sphincterotomy and discusses the clinical indications and technical methods for representative methods of effective gallstone removal.
Ampulla of Vater ; Catheterization ; Choledocholithiasis ; Common Bile Duct ; Gallstones ; Hemorrhage ; Incidence ; Methods ; Pancreatitis ; Sphincterotomy, Endoscopic

Common bile duct stones (CBDS) are estimated to be present in 10–20% of individuals with symptomatic gallstones. Most patients with gallstones remain asymptomatic throughout their lifetime, but 10–25% of them may develop biliary pain or complications including pain, jaundice, infection and acute pancreatitis, with an annual risk of about 2–3% for symptomatic disease and 1–2% for major complications. The primary treatment, endoscopic retrograde cholangio-pacreatography (ERCP), is minimally invasive but associated with adverse events in 6% to 15% of patients. Therefore, exact evaluation of CBDS is important in patients with gallstones. Clinicians are therefore confronted with a number of potentially valid options such as endoscopic ultrasonography versus magnetic retrograde cholangiopancreatography in order to diagnose suspected CBDS. The aim of this review for evaluation of patients suspected of common bile duct stone is to provide practical advice on how to manage patients with CBDS. It considers diagnostic strategies in patients with suspected CBDS, as well as the different therapeutic options available for CBDS.
Choledocholithiasis ; Common Bile Duct ; Endosonography ; Gallstones ; Humans ; Jaundice ; Pancreatitis

PURPOSE: The prognosis of periampullary cancer varies with its origin and early diagnosis influences outcome. Endoscopic ultrasound, computed tomography, fine needle aspiration, and fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸FDG-PET/CT) are helpful for diagnosis. This study evaluates the diagnostic efficacy of ¹⁸FDG-PET for preoperative periampullary tumors.METHODS: A series of 100 patients undergoing ¹⁸FDG-PET/CT before surgical resection of periampullary tumors between March 2011 and February 2019 were enrolled. Maximum standardized uptake value (SUVmax) and carbohydrate antigen 19-9 (CA19-9) levels were compared with pathohistological confirmation of periampullary tumors.RESULTS: The SUVmax and uptake range varied with the origin of the periampullary tumors. The SUVmax was not available for 17 of the 42 pancreas tumors, three of 30 common bile duct tumors, and four of 18 ampulla of Vater tumors. The median SUVmax was 0.0 in benign tumors and 5.05 in malignant tumors. The mean SUVmax was 4.1±5.6 in pancreatic tumors, 3.9±2.4 in ampulla of Vater, and 6.0±3.7 in common bile duct. The SUVmax was higher in common bile duct tumors than others. CA19-9 level was of diagnostic value in pancreatic tumor patients. The median CA19-9 levels were 7.64 U/mL (range, 2.71–45.05 U/mL) in benign tumors and 91.97 U/mL (range, 26.91–276.60 U/mL) in cancers patients.CONCLUSION: Preoperative SUVmax and CA19-9 level were of diagnostic value for periampullary tumors originating in the pancreas.
Ampulla of Vater ; Biopsy, Fine-Needle ; CA-19-9 Antigen ; Common Bile Duct ; Diagnosis ; Early Diagnosis ; Fluorodeoxyglucose F18 ; Humans ; Pancreas ; Pancreatic Neoplasms ; Prognosis ; Ultrasonography