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

4_Fujii_LauASGE cholangitis 2023

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The document, authored by Dr. Larissa Fujii-Lau, Associate Professor of Medicine at the University of Hawaii, discusses the evolving role of endoscopy in the management of cholangitis. The key points focus on the diagnosis, severity assessment, treatment options, and endoscopic techniques for cholangitis.<br /><br />**Diagnosis and Case Presentation:**<br />A case of a 71-year-old woman with a fever, epigastric pain, and elevated inflammatory markers suggests cholangitis, though initial imaging showed no gallbladder or bile duct dilation. An evaluation based on the Tokyo Guidelines (TG18/TG13) is suggested for accurate diagnosis.<br /><br />**Severity Assessment:**<br />The case details the need to evaluate additional physical exam findings and lab results to determine severity. The severity is classified as severe if any one criterion is met or moderate if at least two criteria are met based on cardiovascular, neurological, respiratory, renal, hepatic, and hematologic assessments.<br /><br />**Treatment Options:**<br />Treatment varies by severity. ERCP (Endoscopic Retrograde Cholangiopancreatography) within 48 hours is suggested for moderate cases, focusing on biliary sphincterotomy, stone extraction, and stent placement. For severe cases or certain clinical situations, percutaneous transhepatic biliary drainage (PTBD) or EUS-guided biliary drainage may be recommended.<br /><br />**Endoscopic Techniques:**<br />- **Biliary Aspiration:** Essential for culture to tailor antibiotic regimens.<br />- **Biliary Sphincterotomy (BS):** Though effective, it carries bleeding risks, especially in severe cases with coagulopathy.<br />- **Endoscopic Papillary Balloon Dilation (EPBD):** Used for small stones but with a higher pancreatitis risk.<br />- **Endoscopic Papillary Large Balloon Dilation (EPLBD):** Suitable for large stones but may require a two-session approach due to adverse effects.<br /><br />**Summary:**<br />Endoscopic management strategies are tailored based on clinical presentation. For mild/moderate cases, single-session BS is preferred, whereas severe cases may require an initial decompression. Situations involving inaccessible papilla, inability to tolerate sedation, or malignant biliary obstructions have specific endoscopic or percutaneous drainage recommendations.<br /><br />The document emphasizes a structured approach to diagnosing and treating cholangitis, with a strong focus on the appropriate use of endoscopic techniques per individual patient scenarios.

Keywords

cholangitis

endoscopy

diagnosis

severity assessment

treatment options

ERCP

biliary drainage

Tokyo Guidelines

endoscopic techniques

Dr. Larissa Fujii-Lau