Microbiology of bile in patients with cholangitis or cholestasis and plastic biliary endoprosthesis

ERCP--BILIARY ~401

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MICROBIOLOGY OF BILE IN PATIENTS W I T H CHOLANGITIS Ok CHOLESTASIS AND PLASTIC BILIARY ENDOPROSTHESIS. E Esber, S Sherman, J Pezzi, K Gottlieb, D Earle, G Lehman, Indiana university Medical Center. Cholangitis is a frequent c o m p l i c a t i o n of biliary stents, Empiric antibiotic selection is b a s e d p r i m a r i l y on th~ results of bile cultures o b t a i n e d from surgical patients and limited data from the ERCP s t e n ~ e r a . This s t u d y was u n d e r t a k e n to analyze the m i c r o b i o l o g y of bile and th~ sensitivities of the organisms identified in stented patients presenting with clinical cholangitis or cholestasis: METHODS= We r e t r o s p e c t i v e l y reviewed all bile cultures collected during ERCP from ii/93 to 11/94. specimens were collected with a sterile catheter p r i o r to the injection of contrast. All d u o d e n o s c o p e s were washed for 20 minutes in 2% g l u t a r a l d e h y d e just prior to use. RESULTS: Forty-three cultures from 34 patients ranging in age from 24-85 (mean 64) w e r e identified. Twenty-twe patients (31 cultures) had indwelling plastic b i l i a r y stents at the time of culture (Group i) and 12 patients 12 cultures) had no stents (GroUp 2). The p r l m a r y diagnosis for patients in Groups 1,2 were: m a l i g n a n t bile duct obstruction (16,4), c h o l e d o c h o l i t h i a s i s (n=0,4), benign stricture from chronic p a n c r e a t i t i s (n=3,2), anastomotic stricture after l i v e r t r a n s p l a n t a t i o n (n=3t2), Grp 1 (n=31} Gro 2 tn=12t POSitive cultures 29 8 Total organisms 21 11 Fever 27 (93%) 9 (83%) prior antibiotics 25 (81%) 9 (75%) EnterococcuslEC) 22 (71%)(p<0001) 2 (17%) Enterobacteriaceae Sp. IEB l 12 (39%) 5 (41%) Candida(CN l 12 (39%) 2 (17%) pseudomonas 3 (!0%) 1 ( 8%} Polymicrobial 25 (81%)(p<0.001) 3 (34%)

CUTTING T H E P A P I L L A C L O S E R AND SAFER: A N E W T E C H N I Q U E OF NEEDLE KNIFE S P H I N C T E R O T O M Y . K.P, Etzkorn, R.P. Venu, R.D. Brown, D.E. McGuire, and A. AbuHammour, University of Illinois at Chicago, Chicago, IL 60612. Needle knife sphineterotomy (NKS) is sometimes performed in patients with bile duet obstruction when conventional endoscopic sphincterotomy is unsuccessful. However, NKS can be technically difficult when the papilla is too small, the papillary orifice is stenosed, and in the presence of duodenal diverticulum. The aim of this study was to see whether altering the anatomy of the papilla by saline injection would facilitate NKS. METHODS. Of 300 endoscopic sphincterotomies performed at our facilities during the past year, 31 patients underwent NKS. Of these 31 patients, 8 patients had unusual anatomy of the papilla necessitating saline injection prior to needle knife sphincterotomy (SINKS). All 8 patients had papillas less than 5 ram in diameter, 4 patients had periampullary diverticula, 3 patients had papillary stenosis, and 1 patient had extrinsic compression of the duodenum, making landmark identification difficult. All patients had 2 or more ERCPs with unsuccessful cannulation of the papilla prior to referral to our facilities. TECHNIQUE. A duodenoscope is positioned in the descending duodenum, the papilla is visualized en face. A sclerotherapy needle is inserted 1 to 2 nun above the superior margin of the papillary orifice at a 12 o'clock position, normal saline is injected at increment of .5 cc until the papilla bulges into the duodenal l u m e n . NKS is performed next after placing the needle at a 12 o'clock position with incremental incision cephalad until a gush of bile is noted. Further therapy such as stone extraction, or stent placement is carried out. RESULTS. All but 1 patient had successful SINKS at the first attempt; 1 patient needed a second attempt. One patient developed mild pancreatitis. CONCLUSION. 1) In patients with a tiny papilla and difficult anatomy, saline injection makes the papilla more prominent. 2) Creating a bulging papilla facilitates NKS and may avoid potential complications.

Antibiotic sensitivities for Grp i patients w i t h EC were: v a n c o m y c i n lYe) 100%, n o r f l o x a c i n (NF) 45% and ampicillin 9%. The gram negative rod (GNR} organisms in Grp 1 had the following antibiotic sensitivlties: imipenem (IP) 97%, ciprofloxacin (CF) 86%, and c e f o p e r a z o n e ICP) 83%. SbT~MARY: EC, EB or CN were present in 93% of bile cultures in patients with cholangitis/cholestasis and b i l i a r y stents. Grp 1 patients had a significant p r e v a l e n c e of EC and p o l y m i c r o b i a l cultures compared to Grp 2. VC and either IP, CF, or CP would provide the b r o a d e s t antibiotic coverage for Grp 1 patients. CONCLUSION= Since Q u i n o l o n e s (CF,NF l effectively p~netrate into the o b s t r u c t e d biliary tree and can be administered orally, they can provide excellent GNR an~ good EC coverage for Grp 1 patients prior to stent exchange. The role of CN as a p u t a t i v e o r g a n i s m for chelangitis or stent occlusion is unknown.

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PHOSPECTIVE ASSESSMENT OF BILIARy SCINTIGRAPHY (BS} COMPARED TO S P H I N C T E R OF ODDI M A N O M E T R Y (SOM) IN PATIENTS W I T H SUSPECTED S P H I N C T E R OF ODDI DYSFUNCTION, E Esber, T Ruffolo, H Park, A Siddiqui, D Earle, J Pezzi, K Gottlieb, S Sherman, G Lehman. Indiana U n i v e r s i t y Medical Center. Previous studies have shown the benefit of BS in d i s c r i m i n a t i n g patients with abnormal versus normal SOM. The Hopkins group I devised a p a r a m e t r i c score of" as after cholecystokinin (CCK) bolus w h i c h d e m o n s t r a t e d a high sensitivity and specificity for Sphincter of Oddi dysfunction (SOD). We u t i l i z e d the Hopkins' score in a group of patients u n d e r g o i n g BS w i t h bolus and continuous CCK infusion. METHODS: T w e n t y - n i n e Type II and III (modified H o g a n - G e e n e n classification) p o s t c h o l e c y s t e c t o m y patients were e v a l u a t e d by BS and E R C P w i t h SOM. ERCP was p e r f o r m e d to exclude bile or pancreatic duct abnormalities. Basal sphincter manometric p r e s s u r e s greater t h a n 40 m m H g were considered abnormal. B a s e l i n e and CCK stimulated nS w e r e p e r f o r m e d on separate days after a d m i n i s t e r i n g DISIDA. A 20 ng/kg IV bolus of CCK followed by an infusion of 91.4 ng/kg/hr were administered for the stimulated BS. DISIDA activity was m e a s u r e d at i m i n u t e intervals from regions of interest lROI) drawn over the right lobe of the liver, hepatic hilum and common bile duct. A c t i v i t y curves were calculated including duodenal arrival time (DAT) and hilum t~ duodenal time (HDT). TWO b l i n d e d nuclear medicine specialists independently r e v i e w e d each scintigraphic image and ROI curves, and then c a l c u l a t e d a Hopkins' Score; differences were resolved by consensus. RESULTS: Two patients were excluded due to duodenal overlap of the common bile duct w i t h D I S ~ D A tracer. There was no statistical difference in Hopkins' score, DAT or HDT in abnormal versus normal SOM patients.

CRYSTALS IN THE BILIARY TRACT ARE NOT AFFECTED BY INJECTION OF IODINATED CONTRAST DURING ERCP. M. Firouzi, (~ Khusro, J. Leya. Loyola University Medical Center, Maywood, IL, Hines VA Hospital, Hines, IL. Background: Microscopicexaminationof stimulated duodenal bile has long becn the subject of interest, but with the advent of modern imaging procedures it has been used less frequently. However,even after ERCP the gold standard technique for pancreato-biliary imaging, some patients are left without a diagnosis, particularlywhen the possibilityof microlithiasisis considered~ It has been shown that duodenal bile is dilute as compared with gallbladder bile but is qualitatively similar to the latter in predicting the nature of gallstones by microscopic examination. In a recent study in patients undergoing ERCP it was shown that microscopicexamination of bile obtained before injection of contrast had a high specificity for detection of gallstones. Since obtaining bile requires selective cannulation of the bile duct that frequently requires injection of contrast, we designed this study to compare the microscopic examination of bile obtained before and after contrast injection in patients undergoing ERCP. Here we report our preliminary data. Subjects: 11 consecutive patients undergoing ERCP examination at Loyola University Medical Center and Hines VA Hospital. Methods: Bile was obtained by selective caunulation of the bile duct before and al~erinjection of contrast. 2-3 ml samples were centrifuged at 2000 rpm for 10 minutes and examined under polarized microscope. Results: in all 11 patients absolute concordance was seen (refer to table).

Baseline Hopkins' Score

BS

Stimulated BS

b

mean

mean

Abnormal SOM (n ~ 12)

3.57

1.82

.078

Normal SOM (n = 17)

Crystals present

3.00

1,71

.110

Duodenal Arrival Time (rain)

14.5 + 6.3

11.2 + 4.8

< 0.05

Hilum to Duodenal Time (rain)

6.0_+ 3.6

4,7 + 2.4

< 0.05

Pre-Contrast Injection

Post-Contrast Injection

5

5

Crystals absent 6 6 Conclusion. Injection of contrast does not affect the presence of crystals in the bile duct. Hence, we recommend microscopic examination of bile obtained by whichever teclmique is easiest in a given individual patient.

S~MMARY : BS w i t h bOlUS and continuous CCK infusion decreases the transit time of D I S I D A tracer. Stimulated and b a s e l i n e BS did not d i f f e r e n t i a t e abnormal from normal SOM by DAT, HDT or Hopkins' sco~e. CONCLUSIONS= This study fails to confirm the benefit of BS Hopkins' scoring system in predicting SOD in Type II and III p a t i e n t s w i t h abnormal manometry. A larger study including normal controls may be beneficial. I 8ostre et al. J Nucl Med. 1992;33:1216-1222

396

GASTROINTESTINAL

ENDOSCOPY

V O L U M E 41, N O . 4, 1995