Endoscopic Biliary Drainage by Nasobiliary Drain or by Stent Placement in Patients with Acute Cholangitis

Background and Study Aims: Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of nasobiliary drain (NBD) placement and stent placement for biliary drainage in patients with acute cholangitis.
Patients and Methods: We recruited a total of 150 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7-Fr NBD or a 7-Fr straight flap stent placed during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and the clinical outcome.
Results: Of the 150 patients, 75 were randomized to the NBD group and 75 to the stent group. The most common causes of biliary obstruction were common bile duct stones (n = 102) and biliopancreatic malignancies (n = 37). The site of the biliary obstruction was predominantly found to be the lower part of common bile duct in both the NBD group (n = 58) and the stent group (n = 59). Indications for biliary drainage were: a fever of > 100.4° F (n = 140), hypotension (n = 23), peritonism (n = 40), impaired consciousness (n = 29), and failure to improve with conservative management (n = 45). Biliary drainage was achieved in 147 patients. Abdominal pain, fever, jaundice, hypotension, peritonism and altered sensorium improved after a median period of 2 days in both groups. Leukocyte counts became normal after a median time of 7 days in the NBD group and 6 days in the stent group. There were no ERCP-related complications. There were no instances of displacement or kinking of an NBD, occlusion of an NBD or stent, or of stent migration. Four patients died (two in the NBD group and two in the stent group) as a result of uncontrolled cholangitis after 1, 2, 4, and 6 days of biliary drainage. The success rates of biliary drainage in cholangitis were not affected by the type of endoprosthesis used (72/74 for NBD patients vs. 71/73 for stent patients), the etiology of the biliary obstruction (110/112 for benign obstruction vs. 33/35 for malignant obstruction), or the site of the biliary obstruction (28/30 for upper common bile duct obstruction vs. 115/117 for obstruction at the lower end of common bile duct).
Conclusions: Biliary drainage by nasobiliary drain and drainage by stent are equally safe and effective treatments for patients with severe cholangitis.

References

• 1 Boey J H, Way L H. Acute cholangitis.  Ann Surg. 1980;  191 264-270
• 2 Magun A. Acute cholangitis - endoscopic drainage or emergency surgery?.  Gastroenterology. 1990;  99 1530-1531
• 3 Ressa M E, Hawkins I F, Vogel S B. The treatment of acute cholangitis: percutaneous transhepatic biliary drainage before definitive therapy.  Ann Surg. 1987;  205 389-392
• 4 Huang S M, Yu S C, Tsang Y M. et al . Complication of percutaneous transhepatic cholangiography and biliary drainage.  J Clin Gastroenterol. 1989;  96 446-452
• 5 Lent A UGV, Bartelsman J FWM, Tytgat G NJ. et al . Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract.  Gastrointest Endosc. 2002;  55 518-522
• 6 Lai E CS, Paterson I A, Tam P C. et al . Severe acute cholangitis: the role of emergency nasobiliary drainage.  Surgery. 1990;  107 268-272
• 7 Leung J W, Chung S C, Sung J J. et al . Urgent endoscopic drainage for acute suppurative cholangitis.  Lancet. 1989;  1 1307-1309
• 8 Chawla Y K, Sharma B C, Dilawari J B. Endoscopic nasobiliary drainage in acute suppurative cholangitis.  Indian J Gastroenterol. 1994;  13 83-85
• 9 Leese T, Neoptolemos J P, Carr-Locke D L. Successes, failures, early complications and their management following endoscopic sphincterotomy: results in 394 consecutive patients from a single centre.  Br J Surg. 1985;  72 215-219
• 10 Leese T, Neoptolemos J P, Baker A R, Carr-Locke D L. Management of acute cholangitis and the impact of endoscopic sphincterotomy.  Br J Surg. 1986;  73 988-992
• 11 Chawla Y K, Sharma B C, Singh R. et al . Emergency endoscopic nasobiliary drainage without the aid of fluoroscopy.  Indian J Gastroenterol. 1993;  12 97-98
• 12 Lai E C, Mok F P, Tan E S. et al . Endoscopic biliary drainage for severe acute cholangitis.  N Engl J Med. 1992;  326 1582-1586
• 13 Lin X IZ, Chang K K, Shin J S. Emergency endoscopic nasobiliary drainage for acute suppurative calculous cholangitis and its potential use in chemical dissolution.  J Gastroenterol Hepatol. 1993;  8 35-38
• 14 Cotton P B. Endoscopic drainage for suppurative cholangitis.  Lancet. 1989;  2 213
• 15 Sharma B C, Agarwal D K, Baijal S S. et al . Endoscopic management of acute calculous cholangitis.  J Gastroenterol Hepatol. 1997;  12 574-576
• 16 Lam S K. A study of endoscopic sphincterotomy in recurrent pyogenic cholangitis.  Br J Surg. 1984;  71 262-266
• 17 Gogel H K, Runyon B A, Volpicelli N A, Palmer R C. Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy.  Gastrointest Endosc. 1987;  33 210-213
• 18 Hui C K, Lai K C, Yuen M F. et al . Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis?.  Gastrointest Endosc. 2003;  58 500-504
• 19 Leung J W. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis?.  Gastrointest Endosc. 2003;  58 570-572
• 20 Misra S P, Dwivedi M. Biliary endoprosthesis as an alternative to endoscopic nasobiliary drainage in patients with acute cholangitis.  Endoscopy. 1996;  28 746-749
• 21 Lee D WH, Chan A CW, Lam Y H. et al . Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial.  Gastrointest Endosc. 2002;  56 361-365
• 22 Lau J Y, Ip S M, Chung S C. et al . Endoscopic drainage aborts endotoxemia in acute cholangitis.  Br J Surg. 1996;  83 181-184
• 23 Sharma B C, Agarwal D K. Etiopathogenesis, clinical features and management of acute cholangitis.  J Assoc Physicians India. 1995;  43 422-426
• 24 Ikeda S, Tanaka M, Itoh H. et al . Emergency decompression of bile duct in acute obstructive suppurative cholangitis by duodenoscopic cannulation: a lifesaving procedure.  World J Surg. 1981;  5 587-593
• 25 Sugiyama M, Atomi Y. The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis.  Am J Gastroenterol. 1998;  93 2065-2068
• 26 Kumar R, Sharma B C, Singh J, Sarin S K. Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction due to malignant and benign diseases.  J Gastroenterol Hepatol. 2004;  19 994-997
• 27 Thompson J, Bennion R S, Pitt H A. An analysis of infectious failures in acute cholangitis.  HPB Surg. 1994;  8 139-144
• 28 O’Connor M J, Schwartz M, McQuarrie D G, Summer H W. Acute bacterial cholangitis: an analysis of clinical manifestation.  Arch Surg. 1982;  117 437-441