ASGE Postgraduate Course at ACG: Innovative Practices for the Endoscopist of Today, Tomorrow and Beyond | October 2023-4_Fujii

4_Fujii_LauASGE cholangitis 2023

Pdf Summary

The document, authored by Dr. Larissa Fujii-Lau, discusses the role of endoscopy in managing cholangitis, focusing on diagnosis, severity assessment, and treatment options, particularly via endoscopic techniques. <br /><br />**Diagnosis:** The case of a 71-year-old woman presenting with fever and epigastric pain is used to illustrate diagnostic challenges. Initial negative imaging results might still be consistent with cholangitis if markers and clinical symptoms match.<br /><br />**Severity Assessment:** Severity is judged based on markers like blood pressure, white blood cell count, temperature, and bile duct dilation, among others. Criteria from the Tokyo Guidelines (TG18/TG13) are employed to guide the assessment.<br /><br />**Treatment Options:** <br />- **Percutaneous Transhepatic Biliary Drainage (PTBD) and Endoscopic Retrograde Cholangio-Pancreatography (ERCP):** ERCP is generally beneficial, reducing inpatient mortality and hospital stay lengths. However, the timing of ERCP is crucial to optimize outcomes; urgent ERCP (within 24 hours) can result in lower mortality rates in certain patient subsets.<br />- **Bile Cultures:** Routine collection during biliary drainage is recommended to tailor antibiotic regimens effectively.<br />- **Endoscopic Techniques:** Various techniques are discussed for managing bile stones and obstructions, including:<br />  - **Biliary Sphincterotomy:** While effective, it carries bleeding risks. It's generally avoided in patients with coagulopathy or recent antithrombotic use.<br />  - **Endoscopic Papillary Balloon Dilation (EPBD):** It’s less successful for stone removal compared to sphincterotomy but has a lower bleeding risk.<br />  - **Endoscopic Papillary Large Balloon Dilation (EPLBD):** Recommended for larger stones, preferably performed in staged sessions to manage risks.<br />  - **Biliary Stenting:** Advised in most patients, with plastic stents being common. Metal stents might be used in cases of malignancy or high bleeding risk.<br />  - **EUS-guided biliary drainage:** Viable for patients where ERCP is not feasible.<br /><br />The document concludes by emphasizing individualized treatment plans based on the clinical presentation and severity of cholangitis, recommending appropriate endoscopic techniques accordingly.

Keywords

cholangitis

endoscopy

diagnosis

severity assessment

treatment options

ERCP

biliary drainage

endoscopic techniques

biliary stenting

Tokyo Guidelines