Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

doi:10.12998/wjcc.v11.i29.6984

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Oct 16, 2023 (publication date) through May 13, 2024

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World Journal of Clinical Cases

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Retrospective Cohort Study

World J Clin Cases. Oct 16, 2023; 11(29): 6984-6994
Published online Oct 16, 2023. doi: 10.12998/wjcc.v11.i29.6984

Table 1 Cancer type, stage, and location of obstruction in malignant biliary obstruction

	MBO group (n = 56)
Etiology of MBO
Pancreatic cancer	24 (42.9%)
Stage I/II/III/IV	1/6/3/14
Ampulla of Vater cancer	13 (23.2%)
Adenoma	2
Cancer, stage I/II/III/IV	4/3/3/1
CBD cancer	6 (10.7%)
Stage I/II/III/IV	1/4/0/1
Klatskin tumor	3 (5.4%)
Stage I/II/III/IV	0/0/0/3
Metastatic tumor	6 (10.7%)
Hepatocellular carcinoma	2 (3.6%)
Gallbladder cancer	2 (3.6%)
Stage I/II/III/IV	0/0/0/2
Location of obstruction
Distal EHD	46 (82.1%)
Perihilar obstruction	10 (17.9%)
Bismuth-Corlette type I	4
Bismuth-Corlette type II	6

MBO: Malignant biliary obstruction; CBD: Common bile duct; EHD: Extrahepatic bile duct.

Table 2 Patient characteristics, laboratory values, and clinical outcomes

Variables¹	Overall cases (n = 512)			Propensity-score matched cases (n = 110)
Variables¹	MBO group (n = 56)	CBDS group (n = 460)	P value	MBO group (n = 55)	CBDS group (n = 55)	P value
Age (yr)	69 (56.8-77.8)	66 (54-78)	0.626	69 (57-80)	69 (59-83)	0.429
Male gender, n (%)	35 (62.5)	263 (57.2)	0.446	35 (63.6)	29 (52.7)	0.246
Body temperature (°C)	36.9 (36.6-37.7)	37.4 (36.9-38.4)	0.001	36.9 (36.6-37.8)	37.5 (37.0-38.1)	0.003
Abnormal WBC count², n (%)	23 (41.1)	280 (60.9)	0.004	23 (41.8)	35 (63.6)	0.022
Platelet count (/µL)	237 (169-307.5)	197.5 (150-249.3)	0.011	238.5 (169.5-312.3)	181.5 (142.8-238.3)	0.002
PT/INR	1.2 (1.1-1.3)	1.1 (1.1-1.2)	0.028	1.2 (1.1-1.3)	1.2 (1.1-1.2)	0.23
AST (U/L)	109 (71-209)	167 (91-331)	0.014	109 (71-221.8)	197 (85-453)	0.037
ALT (U/L)	103 (61-198)	189 (102-330)	0.001	104 (58.5-214.5)	140.5 (68-378.8)	0.18
ALK-P (U/L)	357 (224-548)	181.5 (125.3-282)	< 0.001	357 (220-550)	163 (121-252.8)	< 0.001
Total bilirubin (mg/dL)	8.2 (4-12.8)	3.7 (2.4–5.9)	< 0.001	7.5 (3.6-12.7)	3.4 (2.2-5.1)	< 0.001
Creatinine (mg/dL)	0.8 (0.7-1.0)	1.0 (0.7-1.3)	0.004	0.8 (0.7-1.0)	0.9 (0.7-1.4)	0.052
Organ dysfunction, n (%)
Cardiovascular	0 (0)	20 (4.3)	0.15	0	2 (3.6)	0.495
Neurological	6 (10.7)	24 (5.2)	0.122	5 (9.1)	5 (9.1)	1
Respiratory	4 (7.1)	32 (7.0)	1	4 (7.3)	8 (14.5)	0.221
Renal	4 (7.1)	37 (8.0)	1	4 (7.3)	2 (3.6)	0.679
Hepatic	4 (7.1)	10 (2.2)	0.063	4 (7.3)	0	0.118
Hematological	5 (8.9)	27 (5.9)	0.372	5 (9.1)	7 (12.7)	0.54
Severity of AC, n (%)						0.803
Mild	21 (37.5)	231 (50.2)	0.072	21 (38.2)	22 (40.0)	0.845
Moderate	16 (28.6)	128 (27.8)	0.907	16 (29.1)	13 (23.6)	0.516
Severe	19 (33.9)	101 (22.0)	0.045	18 (32.7)	20 (36.4)	0.688
Time to ERCP (h)
Overall cases	92.5 (43.9-137.0)	47.4 (26.0-82.3)	< 0.001	89.9 (41.6-137.0)	71.5 (41.8–109.5)	0.418
Mild AC	89.9 (40.9-116.3)	47.3 (28.2-84.0)	0.026	89.9 (38.9-116.4)	74.6 (39.3–114.8)	0.923
Moderate AC	113.1 (65-162.3)	44.5 (24.2-70.4)	< 0.001	113.1 (51.8-163.2)	55.1 (38.1-119.2)	0.11
Severe AC	68.8 (37.0-139.6)	65.9 (25.2-90.7)	0.133	67.4 (29.1-139.4)	77.6 (49.5-120.7)	0.74
ERCP success rate, n (%)	53 (94.6)	456 (99.1)	0.031	53 (96.4)	51 (92.7)	0.679

¹Data are presented as medians (interquartile ranges) for continuous variables and as n (%) for categorical variables.

²Abnormal white blood cell count (WBC) was defined as WBC < 4000/µL or > 12000/µL.

MBO: Malignant biliary obstruction; CBDS: Common bile duct stones; WBC: White blood cell count; PT/INR: Prothrombin time/international normalized ratio; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALK-P: Alkaline phosphatase; AC: Acute cholangitis; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Primary and secondary outcomes

Variables¹	Overall cases (n = 512)			Propensity-score matched cases (n = 110)
Variables¹	MBO group (n = 56)	CBDS group (n = 460)	P value	MBO group (n = 55)	CBDS group (n = 55)	P value
30-d mortality, n (%)	3 (5.4)	3 (0.7)	0.019	2 (3.6)	0	0.495
ICU admission, n (%)	7 (12.5)	22 (4.8)	0.028	7 (12.7)	3 (5.5)	0.185
LOHS (d)¹	16.5 (9.8-34.8)	7 (5-9)	< 0.001	16 (9-37)	8 (6-11)	< 0.001
30-d readmission, n (%)	13 (23.2)	37 (8.0)	< 0.001	13 (23.6)	6 (10.9)	0.077

¹Data are presented as medians (interquartile ranges) for continuous variables and as n (%) for categorical variables.

MBO: Malignant biliary obstruction; CBDS: Common bile duct stones; ICU: Intensive care unit; LOHS: Length of hospital stay.

Table 4 Univariate and multivariate analyses of factors associated with 30-d mortality

Variables		Univariate analysis		Multivariate analysis
Variables		OR (95%CI)	P value	OR (95%CI)	P value
Age	Every 1-yr increase	1.015 (0.964-1.068)	0.576	-	-
Sex	Male	0.143 (0.017-1.237)	0.077	-	-
Sex	Female	Referent	0.077	-	-
Etiology	MBO	8.623 (1.697-43.806)	0.009	5.346 (0.524-54.491)	0.157
Etiology	CBDS	Referent	0.009	5.346 (0.524-54.491)	0.157
Fever (BT ≥ 39 °C)	Yes	1.394 (0.160-12.121)	0.764	-	-
Fever (BT ≥ 39 °C)	No	Referent	0.764	-	-
Abnormal WBC count	Yes	1.411 (0.256-7.776)	0.692	-	-
Abnormal WBC count	No	Referent	0.692	-	-
Hyperbilirubinemia (≥ 5 mg/dL)	Yes	0.836 (0.152-4.608)	0.837	-	-
Hyperbilirubinemia (≥ 5 mg/dL)	No	Referent	0.837	-	-
Time to ERCP	Every 1-d delay	1.931 (1.210-3.081)	0.006	1.977 (1.027-3.807)	0.041
Failure of ERCP	Yes	16.88 (1.696-166.389)	0.016	27.116 (0.979-751.028)	0.051
Failure of ERCP	No	Referent	0.016	27.116 (0.979-751.028)	0.051
Hepatic dysfunction (PT-INR > 1.5)	Yes	17.917 (2.986–107.492)	0.002	NI	-
Hepatic dysfunction (PT-INR > 1.5)	No	Referent	0.002	NI	-
Hematological dysfunction (PLT < 100 × 10³/µL)	Yes	3.058 (0.347-26.987)	0.314	-	-
Hematological dysfunction (PLT < 100 × 10³/µL)	No	Referent	0.314	-	-
Renal dysfunction (Cr > 2.0 mg/dL)	Yes	2.315 (0.264-20.300)	0.449	-	-
Renal dysfunction (Cr > 2.0 mg/dL)	No	Referent	0.449	-	-
Respiratory dysfunction (PaO₂/FiO₂ ratio > 300)	Yes	14.455 (2.807-74.421)	0.001	NI	-
Respiratory dysfunction (PaO₂/FiO₂ ratio > 300)	No	Referent	0.001	NI	-
Neurological dysfunction (conscious disturbance)	Yes	17.889 (3.447-92.828)	0.001	NI	-
Neurological dysfunction (conscious disturbance)	No	Referent	0.001	NI	-
Cardiovascular dysfunction¹	Yes	29.600 (5.450–154.322)	< 0.001	NI	-
Cardiovascular dysfunction¹	No	Referent	< 0.001	NI	-
Multiple organ dysfunction (≥ 2 organ dysfunction)	Yes	33.172 (5.833-188.666)	< 0.001	49.008 (1.692-1419.861)	0.023
Multiple organ dysfunction (≥ 2 organ dysfunction)	No	Referent	< 0.001	49.008 (1.692-1419.861)	0.023
Severity of AC	Severe	17.174 (1.986-148.479)	0.01	1.496 (0.053-41.837)	0.813
Severity of AC	Moderate + mild	Referent	0.01	1.496 (0.053-41.837)	0.813
ICU admission	Yes	8.944 (1.568-51.014)	0.014	13.667 (0.993-188.394)	0.051
ICU admission	No	Referent	0.014	13.667 (0.993-188.394)	0.051

¹Defined as hypotension requiring dopamine ≥ 5 µg/kg per min, or any dose of norepinephrine.

MBO: Malignant biliary obstruction; CBDS: Common bile duct stones; NI: Not included; AC: Acute cholangitis; BT: Body temperature; WBC: White blood cell count; ERCP: Endoscopic retrograde cholangiopancreatography; Cr: creatine; PT/INR: Prothrombin time/international normalized ratio; PLT: platelet; ICU: Intensive care unit; OR: Odds ratios; CI: Confidence intervals.

Citation: Tsou YK, Su YT, Lin CH, Liu NJ. Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes? World J Clin Cases 2023; 11(29): 6984-6994
URL: https://www.wjgnet.com/2307-8960/full/v11/i29/6984.htm
DOI: https://dx.doi.org/10.12998/wjcc.v11.i29.6984