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Autopsy & Case Reports 2023COVID-19 is commonly associated with high serum levels of pro-inflammatory cytokines, and the post-infection status can disturb self-tolerance and trigger autoimmune...
COVID-19 is commonly associated with high serum levels of pro-inflammatory cytokines, and the post-infection status can disturb self-tolerance and trigger autoimmune responses. We are reporting a 45-year-old male who was admitted with fatigue, jaundice, elevated liver enzymes (with cholestatic pattern), and acute kidney injury two weeks after recovering from a mild SARS-CoV-2 infection. Serologies for viral hepatitis and anti-mitochondrial antibody were negative, while anti-nuclear and anti-smooth muscle antibodies were positive. There were no signs of chronic liver disease, and a magnetic resonance cholangiography showed no dilatation of biliary ducts. Histologic evaluation of the liver evidenced numerous foci of lobular necrosis without ductopenia or portal biliary reaction. Considering the autoantibody profile and histologic changes, the medical team started oral prednisone, but there was a suboptimal biochemical response in the outpatient follow-up. Two months later, a second liver biopsy was performed and revealed non-suppurative destructive chronic cholangitis, extensive areas of confluent necrosis with hepatocytes regenerating into pseudorosettes, and numerous plasma cells. According to the Paris Criteria, the patient was then diagnosed with an autoimmune hepatitis-primary biliary cholangitis overlap syndrome (AIH-PBC-OS). After adding azathioprine and ursodeoxycholic acid to the treatment, there was a satisfactory response. This is the second worldwide report of an AIH-PBC-OS triggered by COVID-19, but the first case with a negative anti-mitochondrial antibody. In this setting, histologic evaluation of the liver by an experienced pathologist is a hallmark of achieving the diagnosis and correctly treat the patient.
PubMed: 37034275
DOI: 10.4322/acr.2023.422 -
Annals of the Academy of Medicine,... Mar 2022
Topics: Anastomosis, Surgical; Cholangitis; Gastroenterostomy; Humans; Pancreatitis; Suppuration
PubMed: 35373246
DOI: 10.47102/annals-acadmedsg.2021376 -
British Journal of Experimental... Dec 1968
Topics: Animals; Cholangitis; Cholelithiasis; Common Bile Duct; Escherichia coli Infections; Gallstones; Liver Diseases; Portal System; Rabbits; Rats; Suppuration
PubMed: 4884386
DOI: No ID Found -
JSLS : Journal of the Society of... 2005The overall prevalence of gallstones in the United States is between 10% and 15%. Eighty-five percent of common bile duct (CBD) stones can be removed by endoscopic... (Review)
Review
OBJECTIVES
The overall prevalence of gallstones in the United States is between 10% and 15%. Eighty-five percent of common bile duct (CBD) stones can be removed by endoscopic sphincterotomy with basket or balloon extraction, or both. The introduction of mechanical lithotripsy improved the results up to 90%. We present one case of retained CBD stone after 2 failed endoscopic sphincterotomies and balloon/basket extraction treated by electrohydraulic lithotripsy (EHL).
METHODS
A fifty-year-old man underwent ERCP for suppurative cholangitis. Because of the failure of stone extraction, he was taken to the operating room for an open cholecystectomy and CBD exploration. The intraoperative cholangiogram showed contrast flowing into the duodenum. Seven weeks later, the patient presented with mild pancreatitis, and a T-tube cholangiogram revealed a stone impacted in the distal CBD. Percutaneous balloon extraction was again unsuccessful.
RESULTS
The patient underwent a single 2.5-hour session of EHL via the T-tube tract. Mild pulmonary edema occurred intraoperatively. Complete clearance of the CBD was obtained without the need for additional ERCP.
CONCLUSIONS
EHL is a valid and effective option for difficult retained common bile duct stones after failed ERCP.
Topics: Gallstones; Humans; Laparoscopy; Lithotripsy; Male; Middle Aged; Sphincterotomy, Endoscopic; Treatment Failure
PubMed: 16121889
DOI: No ID Found -
BMC Gastroenterology Feb 2022Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary...
BACKGROUND
Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.
METHODS
We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.
RESULTS
Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).
CONCLUSION
We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.
Topics: Case-Control Studies; Cholangitis; Diverticulum; Humans; Liver Abscess, Pyogenic; Retrospective Studies
PubMed: 35130860
DOI: 10.1186/s12876-022-02120-4 -
JAMA Network Open Dec 2023Colorectal cancer (CRC) can compromise the mucosal barrier and subsequently allow a route for bacterial invasion into the portal system or systemic circulation. Despite...
IMPORTANCE
Colorectal cancer (CRC) can compromise the mucosal barrier and subsequently allow a route for bacterial invasion into the portal system or systemic circulation. Despite preliminary data suggesting that patients who experienced pyogenic liver abscess (PLA) have higher CRC incidence rates, data from outside the Southeast Asian population are sparse.
OBJECTIVE
To investigate whether there is an association between PLA and the subsequent incidence of diagnosed CRC using the Veterans Health Administration (VHA) cohort.
DESIGN, SETTING, AND PARTICIPANTS
A patient-level matched retrospective cohort study was conducted at 127 VHA hospitals across the US from January 1, 2003, to December 31, 2020. Patients were followed up to 10 years from PLA diagnosis. Data analysis was performed from April 14, 2002, to October 31, 2023. All patients who were admitted to VHA hospitals with a diagnosis of PLA were included. For each patient with PLA, up to 3 controls without diagnosis of PLA, matching age, sex, and health care facility, were selected.
EXPOSURE
Pyogenic liver abscess.
MAIN OUTCOMES AND MEASURES
The primary outcome was CRC diagnosis during the follow-up period. A multivariable Fine-Gray subdistribution regression model with time-dependent coefficient was used to estimate the time-varying hazard ratio (HR) of CRC incidence while accounting for mortality as a competing event.
RESULTS
A total of 8286 patients with PLA (male, 96.5%; mean [SD] age, 65.8 [11.9] years) and 23 201 patient-level matched controls (male, 96.3%; mean age, 65.3 [11.7] years) were included. A diagnosis of CRC was found in a significantly higher proportion of patients with PLA compared with controls (1.9% [159 of 8286] vs 0.8% [196 of 23 201]; P < .001). The incidence of CRC was significantly higher among patients with PLA during the first 3 years from PLA diagnosis (HR, 3.64; 95% CI, 2.70-4.91 at 0.5 years; HR, 2.51; 95% CI, 1.93-3.26 at 1 year; HR, 1.74; 95% CI, 1.33-2.28 at 2 years; and HR, 1.41; 95% CI, 1.05-1.89 at 3 years), but not significant after 3 years. This association was not observed among patients whose PLA was likely secondary to cholangitis or cholecystitis (HR, 1.78; 95% CI, 0.89-3.56 at 0.5 years).
CONCLUSIONS AND RELEVANCE
In this patient-level matched retrospective cohort study, a significantly higher incidence of CRC was observed up to 3 years from PLA diagnosis. The findings suggest that offering CRC screening for patients with cryptogenic PLA may be useful, especially patients who have not been screened according to guidelines.
Topics: Aged; Humans; Male; Incidence; Liver Abscess, Pyogenic; Retrospective Studies; Veterans; Colorectal Neoplasms; Female; Middle Aged
PubMed: 38109112
DOI: 10.1001/jamanetworkopen.2023.48218 -
Comparative Medicine Aug 2022() is a gram-negative opportunistic pathogen that causes severe pneumonia, pyelonephritis, and sepsis in immunocompromised hosts. During a 4-mo interval, several...
() is a gram-negative opportunistic pathogen that causes severe pneumonia, pyelonephritis, and sepsis in immunocompromised hosts. During a 4-mo interval, several NOD./SzJ (NSG) breeders and pups in our facilities were diagnosed with infections. An initial 6 adult and 1 juvenile NSG mice were submitted for necropsy and histologic examination because of acute onset of diarrhea and death. The evaluation revealed typhlocolitis in 2 of the mice and tritrichomoniasis in all 7. positive for polyketide synthase () and were isolated from the intestines. Given a history of sepsis due to in NSG mice in our facilities and determination of its antimicrobial susceptibility, trimethoprim-sulfamethoxazole (TMP-SMX) was administered to the colony in the drinking water for 4 wk. After this intervention, an additional 21 mice became ill or died; 11 of these mice had suppurative pneumonia, meningoencephalitis, hepatitis, metritis, pyelonephritis, or sepsis. was cultured from pulmonary abscesses or blood of 10 of the mice. Whole-genome sequencing (WGS) indicated that the isolates contained genes associated with phenotypes found in pore-forming isolates cultured from humans with ulcerative colitis and primary sclerosing cholangitis. None of the isolates exhibited a hyperviscous phenotype, but 13 of 14 were resistant to TMP-SMX. Antimicrobial susceptibility testing indicated sensitivity of the to enrofloxacin, which was administered in the drinking water. Antibiotic sensitivity profiles were confirmed by WGS of the strains; key virulence and resistance genes to quaternary ammonia compounds were also identified. Enrofloxacin treatment resulted in a marked reduction in mortality, and the study using the NSG mice was completed successfully. Our findings implicate intestinal translocation of as the cause of pneumonia and systemic infections in NSG mice and highlight the importance of identification of enteric microbial pathogens and targeted antibiotic selection when treating bacterial infections in immunocompromised mice.
Topics: Adult; Animals; Anti-Bacterial Agents; Drinking Water; Enrofloxacin; Escherichia coli; Humans; Immunocompromised Host; Klebsiella pneumoniae; Mice; Mice, Inbred NOD; Microbial Sensitivity Tests; Pneumonia; Pyelonephritis; Sepsis; Trimethoprim, Sulfamethoxazole Drug Combination
PubMed: 35882504
DOI: 10.30802/AALAS-CM-21-000088 -
The American Journal of Gastroenterology Apr 2024Despite growing awareness of post-coronavirus disease 2019 (COVID-19) cholangiopathy as one of the most serious long-term gastrointestinal consequences of COVID-19, the... (Observational Study)
Observational Study
INTRODUCTION
Despite growing awareness of post-coronavirus disease 2019 (COVID-19) cholangiopathy as one of the most serious long-term gastrointestinal consequences of COVID-19, the endoscopic features of this disease are still poorly characterized. This study aimed to more precisely define its endoscopic features and to outline the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of this entity.
METHODS
In this observational study, 46 patients with confirmed post-COVID-19 cholangiopathy were included.
RESULTS
Based on the endoscopic features observed in 141 ERCP procedures, post-COVID-19 cholangiopathy can be classified as a variant of secondary sclerosing cholangitis in critically ill patients. It appeared early in the course of intensive care treatment of patients with COVID-19 (cholestasis onset 4.5 days after intubation, median). This form of cholangiopathy was more destructive than stricturing in nature and caused irreversible damage to the bile ducts. A centripetal pattern of intrahepatic bile duct destruction, the phenomenon of vanishing bile ducts, the absence of extrahepatic involvement, and the presence of intraductal biliary casts (85% of patients) were typical cholangiographic features of post-COVID-19 cholangiopathy. This cholangiopathy was often complicated by small peribiliary liver abscesses with isolation of Enterococcus faecium and Candida spp. in bile culture. The prognosis was dismal, with a 1-year liver transplantation-free survival rate of 44%. In particular, patients with peribiliary liver abscesses or destruction of the central bile ducts tended to have a poor prognosis (n.s.). As shown by multivariate analysis, bilirubin levels (on intensive care unit day 25-36) negatively correlated with liver transplantation-free survival (hazard ratio 1.08, P < 0.001). Interventional endoscopy with cast removal had a positive effect on cholestasis parameters (gamma-glutamyl transpeptidase, alkaline phosphatase, and bilirubin); approximately 60% of all individual values decreased.
DISCUSSION
Gastrointestinal endoscopy makes an important contribution to the management of post-COVID-19 cholangiopathy. ERCP is not only of great diagnostic and prognostic value but also has therapeutic value and therefore remains indispensable.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; COVID-19; Cholestasis; Liver Diseases; Bilirubin; Liver Abscess
PubMed: 37843039
DOI: 10.14309/ajg.0000000000002562 -
Oncotarget Sep 2017The levels of Foxo3a in the peripheral blood mononuclears cells (PBMCs) before and after treatment were detected in acute obstructive suppurative cholangitis (AOSC)...
OBJECTIVE
The levels of Foxo3a in the peripheral blood mononuclears cells (PBMCs) before and after treatment were detected in acute obstructive suppurative cholangitis (AOSC) patients to evaluate the associations between Foxo3a and stress hyperglycemia (SHG).
METHODS
PBMCs were obtained from AOSC patients (n=28) on admission (AP), from patients at 1 week after cure (RP) and from healthy volunteers (HV) (n=14) to evaluate the relationship between the protein levels of Foxo3a and the serum levels of glucose. Signaling pathways, which link inflammation and glycometabolism, simultaneously affecting the expression of Foxo3a, were detected. In addition, cytokines were detected in PBMCs and AOSC mouse models, which were pre-treated with Foxo3a agonist.
RESULTS
The levels of glucose and p-Foxo3a in the AP were significantly higher than those in the RP and HV, where as the levels of Foxo3a in the AP were lower than those in the RP and HV. Foxo3a levels in the AP normalized against RP were strongly negatively correlated with the glucose levels in the AP normalized against RP. The levels of sphingosine-1-phosphate receptor 2 (S1PR2) in the AP were higher than those in the RP and HV. In addition, inhibition of Foxo3a phosphorylation, coupled with the down-regulation of S1PR2, attenuated the LPS-induced inflammatory response in the PBMCs and AOSC mouse models.
CONCLUSIONS
Foxo3a is correlated with the dysregulation of glucose homeostasis in the pathogenesis of AOSC-induced sepsis by inhibiting the activation of PI3K/Akt-S1PR2 and NF-κB pathways, hinting at a switched role and therapeutic potentialities in the early stage of sepsis.
PubMed: 29100348
DOI: 10.18632/oncotarget.20011 -
ISRN Gastroenterology 2013Cholangitis, with a clinical spectrum between acute ascending cholangitis and acute fulminant cholangitis, the mildest and the most severe forms, respectively, is the...
Cholangitis, with a clinical spectrum between acute ascending cholangitis and acute fulminant cholangitis, the mildest and the most severe forms, respectively, is the infection of bile ducts with a potential of serious mortality and morbidity. Obstruction of the bile ducts followed by infection, with E. coli being the most commonly isolated agent, is common to all forms of cholangitis. Biliary obstruction is caused by choledocholithiasis mostly. "Choledochal pressure" is the most important factor, determining morbidity. If the pressure exceeds 25 cm H2O, which is the critical value, immune dysfunction ensues. Sepsis is common if the infection of biliary ducts is suppurative. Mortality and morbidity are inevitable if left untreated or drained late. The objective of this study is, in the stand point of the current literature, to analyse the diagnostic, therapeutic success and complication rates of ERCP (Endoscopic retrograde cholangiopancreatography) in patients with a diagnosis of acute purulent cholangitis with no response to medical treatment.
PubMed: 23997958
DOI: 10.1155/2013/191729