Please wait a minute...
Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front Med    2014, Vol. 8 Issue (1) : 118-126     DOI: 10.1007/s11684-014-0306-6
RESEARCH ARTICLE |
Sclerosing cholangitis in critically ill patients: an important and easily ignored problem based on a German experience
Ting Lin1,2, Kai Qu1, Xinsen Xu1, Min Tian1,2, Jie Gao1,2, Chun Zhang1,2, Ying Di1,2, Yuelang Zhang3, Chang Liu1,2()
1. Department of Hepatobiliary Surgery; 2. Surgical Intensive Care Unit; 3. Department of Imaging, the First Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an 710061, China
Download: PDF(268 KB)   HTML
Export: BibTeX | EndNote | Reference Manager | ProCite | RefWorks
Abstract  

Intensive care unit (ICU) is important in the rehabilitation of critically ill patients. In the past decades, many patients who received aggressive treatment in ICU developed sclerosing cholangitis in multiple centers. Sclerosing cholangitis in critically ill patients (SC-CIP) is a relatively new issue. To investigate the causes, clinical manifestation, treatment, and prognosis of SC-CIP, we searched for published cases in the databases of PubMed, Highwire, and Elsevier from 2001 to 2012. Data were extracted using a standard form and retrospectively analyzed. Twelve eligible studies covering 88 patients, with 64 men and 24 women, were enrolled in this analysis. The mean age was 49.8 years. All of the patients recovered from critical illnesses, such as trauma, infection, burn, and major surgeries. High pressure positive end-expiratory pressure (PEEP, peak level at 12.8 cm H2O) was utilized for all patients, with the average duration of 36.3 d. In addition, vasopressor agents were administered in approximately 60% of SC-CIP. A rapid increase in cholestasis and irregular strictures in the intrahepatic bile ducts was observed in the following months. With an average follow-up period of 17.9 months, poor outcomes were observed in 54 patients, including 34 deaths. In conclusion, ischemic injury of the biliary tree, which may be affected by PEEP and/or vasopressor administration, affects cholangiopathic procedure. As a newly discovered type of secondary sclerosing cholangitis, SC-CIP is a severe progressive complication of patients in ICU and should be carefully monitored by clinicians.

Keywords intensive care unit      sclerosing cholangitis      ischemic injury      prognosis      systemic review     
Corresponding Authors: Liu Chang,Email:liuchangdoctor@163.com   
Issue Date: 26 April 2014
URL:  
http://academic.hep.com.cn/fmd/EN/10.1007/s11684-014-0306-6     OR     http://academic.hep.com.cn/fmd/EN/Y2014/V8/I1/118
YearAuthorCountryNo. of patients(male/female)Age(year)
2001Scheppach et al. [3]Germany3 (1/2)32.0±6.6
2002ter Borg et al. [4]Netherland1 (0/1)48
2003Engler et al. [5]Germany9 (5/4) a56.2±17.0
2005Benninger et al. [6]Germany5 (4/1)48.4±20.0
2006Jaeger et al. [7]Germany10 (5/5)55.0±18.2
2007Gelbmann et al. [1]Germany26 (20/6)46.6±17.6
2008Kulaksiz et al. [2]Germany29 (21/8)52.2 b
2008Esposito et al. [8]Germany10 (9/1)49.7±16.6
2009Schnitzbauer et al. [9]Germany1 (1/0)30
2010Al-Benna et al. [10]Germany1 (1/0)48
2010Tian et al. [11]China1 (1/0)22
2012Kwon et al. [12]Korea1 (1/0)68
Total97 (69/28)a49.8b
Tab.1  Summary of SC-CIP cases reported from 2001 to 2012
Fig.1  Articles and number of cases reported in Germany and other countries.
ReferencePrimary critical diseasesTotal
Emergency diseasesPost major surgeryOthersa
TraumaInfectionBurnCardiothoracic surgeryAbdominal surgery
Scheppach et al. [3] 0300003
Engler et al. [5]0100001
Benninger et al. [6] 4010005
Jaeger et al. [7]50000510
Gelbmann et al. [1] 713020426
Kulaksiz et al. [2]555122029
Esposito et al. [8]11170010
Schnitzbauer et al. [9] 1000001
Al-Benna et al. [10] 0010001
Tian et al. [11] 1000001
Kwon et al. [12] 0001001
Total (%)24 (27.3)23 (26.1)8 (9.1)22 (25.0)2 (2.3)9 (10.2)88 (100)
Tab.2  Primary diseases of SC-CIP
ReferenceMechanical ventilationVasopressor administrationc[n/total (%)]
n/TotalTime (d)aPressure(cm H2O)
Scheppach et al. [3]3/344.3±16.210.8±3.82/3 (66.7)
Engler et al. [5] 9/941.1±17.110.1±4.27/9 (77.8)
Benninger et al. [6] 5/530.4±19.815.3±7.43/5 (60.0)
Jaeger et al. [7] 10/1028.0a11.6±6.64/10 (40.0)
Gelbmann et al. [1] 26/2640.7±32.9-b17/26 (65.4)
Esposito et al. [8] 10/1034.3±12.714.9±5.54/10 (40.0)
Schnitzbauer et al. [9]1/128231/1 (100.0)
Al-Benna et al. [10] 1/113121/1 (100.0)
Kwon et al. [12]1/1210/1 (0)
Summary66/6636.312.839/66 (59.1)
Tab.3  Mechanical ventilation and vasopressor treatment performed before SC occurrence
Fig.2  Liver function parameters of different SC-CIP cohorts. (A) The TB levels of patients in the three SC-CIP cohorts were higher than normal ranges. No significant difference was determined among the three cohorts. (B) The ALP levels of patients in the three SC-CIP cohorts were higher than normal ranges. Compared with cohort B, cohorts A and C revealed a significant increase in ALP levels. (One patient was excluded in cohort A.) (C) The GGT levels of patients in three SC-CIP cohorts were higher than normal ranges. The mean level of cohort A was higher than that of cohort B. (Two patients were excluded in cohort A. The detailed data of cohort C was not reported in the original article.) (D and E) Analysis results of 20 patients showed that the ALT and AST levels of SC-CIP were higher than the normal range. The detailed data of cohorts B and C were not reported in the original article.
Fig.3  Pathological progression of ICU-related sclerosing cholangitis. SC-CIP pathogenesis can be divided into four categories, including ischemic causes, toxic causes, infectious causes, and others. The significant pathological changes include stricture and dilation of bile ducts, mixed inflammatory infiltrate, perivenular hepatocellular bilirubinostasis, and hepatocellular damage.
ReferenceDiagnosisTreatment
ERCP(n/total)Biopsy(n/total)Endotherapya(n/total)Antibiotic(n/total)UDCAb(n/total)
Scheppach et al. [3] 3/30/30/33/32/3
ter Borg et al. [4] 1/10/10/11/10/1
Engler et al. [5] 9/97/95/98/99/9
Benninger et al. [6] 5/55/50/53/55/5
Jaeger et al. [7] 10/1010/1010/103/10
Esposito et al. [8] 10/1010/105/10
Schnitzbauer et al. [9] 1/10/11/11/11/1
Al-Benna et al. [10] 1/11/10/11/11/1
Tian et al. [11] 1/10/11/11/10/1
Kwon et al. [12] 1/10/11/11/11/1
Summary (%)42/42 (100.0)33/42 (78.6)18/32 (56.2)27/42 (64.3)19/22 (86.4)
Tab.4  Diagnosis and treatment options for SC-CIP
ReferenceNumber of patientsFollow-up(months)SurviveDeath
Biliary cirrhosisNeed for liver transplantationHepatic failureOthers
Scheppach et al. [3] 311.7 (11–12)2100
ter Borg et al. [4] 114.00100
Benninger et al. [6] 537.8 (12–55)3110
Jaeger et al. [7] 1021.0 (3–54)8101
Gelbmann et al. [1] 25a(4-49)11770
Kulaksiz et al. [2] 2921.0 (1–123)37181
Esposito et al. [8] 1014.4 (2–92)4051
Schnitzbauer et al. [9] 1500100
Al-Benna et al. [10]10100
Tian et al. [11] 1121000
Kwon et al. [12] 16.01000
Summary (%)8717.9 b33 (37.9)20 (23.0)31 (35.6)3 (3.4)
Tab.5  Clinical outcomes of SC-CIP
1 Gelbmann CM, Rümmele P, Wimmer M, Hofst?dter F, G?hlmann B, Endlicher E, Kullmann F, Langgartner J, Sch?lmerich J. Ischemic-like cholangiopathy with secondary sclerosing cholangitis in critically ill patients. Am J Gastroenterol 2007; 102(6): 1221–1229
doi: 10.1111/j.1572-0241.2007.01118.x PMID:17531010
2 Kulaksiz H, Heuberger D, Engler S, Stiehl A. Poor outcome in progressive sclerosing cholangitis after septic shock. Endoscopy 2008; 40(3): 214–218
doi: 10.1055/s-2007-967024 pmid:18264887
3 Scheppach W, Druge G, Wittenberg G, Mueller JG, Gassel AM, Gassel HJ, Richter F. Sclerosing cholangitis and liver cirrhosis after extrabiliary infections: report on three cases. Crit Care Med 2001; 29(2): 438–441
doi: 10.1097/00003246-200102000-00042 pmid:11246328
4 ter Borg PC, van Buuren HR, Depla AC. Bacterial cholangitis causing secondary sclerosing cholangitis: a case report. BMC Gastroenterol 2002; 2(1): 14
doi: 10.1186/1471-230X-2-14 pmid:12057011
5 Engler S, Elsing C, Flechtenmacher C, Theilmann L, Stremmel W, Stiehl A. Progressive sclerosing cholangitis after septic shock: a new variant of vanishing bile duct disorders. Gut 2003; 52(5): 688–693
doi: 10.1136/gut.52.5.688 pmid:12692054
6 Benninger J, Grobholz R, Oeztuerk Y, Antoni CH, Hahn EG, Singer MV, Strauss R. Sclerosing cholangitis following severe trauma: description of a remarkable disease entity with emphasis on possible pathophysiologic mechanisms. World J Gastroenterol 2005; 11(27): 4199–4205
pmid:16015689
7 Jaeger C, Mayer G, Henrich R, Gossner L, Rabenstein T, May A, Guenter E, Ell C. Secondary sclerosing cholangitis after long-term treatment in an intensive care unit: clinical presentation, endoscopic findings, treatment, and follow-up. Endoscopy 2006; 38(7): 730–734
doi: 10.1055/s-2006-925241 pmid:16874910
8 Esposito I, Kubisova A, Stiehl A, Kulaksiz H, Schirmacher P. Secondary sclerosing cholangitis after intensive care unit treatment: clues to the histopathological differential diagnosis. Virchows Arch 2008; 453(4): 339–345
doi: 10.1007/s00428-008-0654-1 pmid:18769938
9 Schnitzbauer AA, Tsui TY, Kirchner G, Scherer MN, Bein T, Schlitt HJ, Obed A. Liver transplantation for sclerosing cholangitis in a polytraumatized patient. Nat Clin Pract Gastroenterol Hepatol 2009; 6(2): 121–126
doi: 10.1038/ncpgasthep1333 pmid:19107104
10 Al-Benna S, Willert J, Steinau HU, Steinstraesser L. Secondary sclerosing cholangitis, following major burn injury. Burns 2010; 36(6): e106–e110
doi: 10.1016/j.burns.2010.01.015 pmid:20381966
11 Tian M, Lv Y, Li J. Hepatobiliary and pancreatic: sclerosing cholangitis associated with critical illness. J Gastroenterol Hepatol 2010; 25(4): 842
doi: 10.1111/j.1440-1746.2010.06316.x pmid:20492345
12 Kwon ON, Cho SH, Park CK, Mun SH. Biliary cast formation with sclerosing cholangitis in critically ill patient: case report and literature review. Korean J Radiol 2012; 13(3): 358–362
doi: 10.3348/kjr.2012.13.3.358 pmid:22563276
13 Abdalian R, Heathcote EJ. Sclerosing cholangitis: a focus on secondary causes. Hepatology 2006; 44(5): 1063–1074
doi: 10.1002/hep.21405 pmid:17058222
14 Ruemmele P, Hofstaedter F, Gelbmann CM. Secondary sclerosing cholangitis. Nat Rev Gastroenterol Hepatol 2009; 6(5): 287–295
doi: 10.1038/nrgastro.2009.46 pmid:19404269
15 Deltenre P, Valla DC. Ischemic cholangiopathy. J Hepatol 2006; 44(4): 806–817
doi: 10.1016/j.jhep.2006.01.009 pmid:16488506
16 Paramythiotis D, Kazamias1 P, Grosomanidis1 V, Kotzampassi K. Splanchnic ischemia during mechanical ventilation. Annals Gastroenterol 2008; 21(1): 45–52
17 Putensen C, Wrigge H, Hering R. The effects of mechanical ventilation on the gut and abdomen. Curr Opin Crit Care 2006; 12(2): 160–165
doi: 10.1097/01.ccx.0000216585.54502.eb pmid:16543794
18 Tr?ger K, Radermacher P, Georgieff M. PEEP and hepatic metabolic performance in septic shock. Intensive Care Med 1996; 22(11): 1274–1275
doi: 10.1007/BF01709351 pmid:9120128
19 Krejci V, Hiltebrand LB, Sigurdsson GH. Effects of epinephrine, norepinephrine, and phenylephrine on microcirculatory blood flow in the gastrointestinal tract in sepsis. Crit Care Med 2006; 34(5): 1456–1463
doi: 10.1097/01.CCM.0000215834.48023.57 pmid:16557162
20 Lee JG, Schutz SM, England RE, Leung JW, Cotton PB. Endoscopic therapy of sclerosing cholangitis. Hepatology 1995; 21 (3): 661–667 78756640270–9139(95)90515–4
21 Narumi S, Roberts JP, Emond JC, Lake J, Ascher NL. Liver transplantation for sclerosing cholangitis. Hepatology 1995; 22(2): 451–457
doi: 10.1002/hep.1840220213 pmid:7635412
22 Harnois DM, Angulo P, Jorgensen RA, Larusso NF, Lindor KD. High-dose ursodeoxycholic acid as a therapy for patients with primary sclerosing cholangitis. Am J Gastroenterol 2001; 96(5): 1558–1562
doi: 10.1111/j.1572-0241.2001.03777.x pmid:11374699
23 Triantos CK, Koukias NM, Nikolopoulou VN, Burroughs AK. Meta-analysis: ursodeoxycholic acid for primary sclerosing cholangitis. Aliment Pharmacol Ther 2011; 34(8): 901–910
doi: 10.1111/j.1365-2036.2011.04822.x pmid:21883323
24 Lindor KD, Kowdley KV, Luketic VA, Harrison ME, McCashland T, Befeler AS, Harnois D, Jorgensen R, Petz J, Keach J, Mooney J, Sargeant C, Braaten J, Bernard T, King D, Miceli E, Schmoll J, Hoskin T, Thapa P, Enders F. High-dose ursodeoxycholic acid for the treatment of primary sclerosing cholangitis. Hepatology 2009; 50(3): 808–814
doi: 10.1002/hep.23082 pmid:19585548
25 Eaton JE, Silveira MG, Pardi DS, Sinakos E, Kowdley KV, Luketic VA, Harrison ME, McCashland T, Befeler AS, Harnois D, Jorgensen R, Petz J, Lindor KD. High-dose ursodeoxycholic acid is associated with the development of colorectal neoplasia in patients with ulcerative colitis and primary sclerosing cholangitis. Am J Gastroenterol 2011; 106(9): 1638–1645
doi: 10.1038/ajg.2011.156 pmid:21556038
26 Katsinelos P, Kountouras J, Chatzimavroudis G, Zavos C, Pilpilidis I, Paroutoglou G. Combined endoscopic and ursodeoxycholic acid treatment of biliary cast syndrome in a non-transplant patient. World J Gastroenterol 2008; 14(33): 5223–5225
doi: 10.3748/wjg.14.5223 pmid:18777601
27 Bansal V, Schuchert VD. Jaundice in the intensive care unit. Surg Clin North Am 2006; 86(6): 1495–1502
doi: 10.1016/j.suc.2006.09.007 pmid:17116459
28 Brienza N, Dalfino L, Cinnella G, Diele C, Bruno F, Fiore T. Jaundice in critical illness: promoting factors of a concealed reality. Intensive Care Med 2006; 32(2): 267–274
doi: 10.1007/s00134-005-0023-3 pmid:16450099
29 Spirt MJ, Stanley S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26(1): 18–20 , 22–28 , quiz 29
pmid:16443807
[1] Xinsen Xu,Yanyan Zhou,Runchen Miao,Wei Chen,Kai Qu,Qing Pang,Chang Liu. Transcriptional modules related to hepatocellular carcinoma survival: coexpression network analysis[J]. Front. Med., 2016, 10(2): 183-190.
[2] Zhi Xu,Chunxiang Cao,Haiyan Xia,Shujing Shi,Lingzhi Hong,Xiaowei Wei,Dongying Gu,Jianmin Bian,Zijun Liu,Wenbin Huang,Yixin Zhang,Song He,Nikki Pui-Yue Lee,Jinfei Chen. Protein phosphatase magnesium-dependent 1δ is a novel tumor marker and target in hepatocellular carcinoma[J]. Front. Med., 2016, 10(1): 52-60.
[3] Aixiu Qiao,Feng Gu,Xiaojing Guo,Xinmin Zhang,Li Fu. Breast cancer-associated fibroblasts: their roles in tumor initiation, progression and clinical applications[J]. Front. Med., 2016, 10(1): 33-40.
[4] Jing Zhang,Shan Gao,Zhongping Duan,Ke-Qin Hu. Overview on acute-on-chronic liver failure[J]. Front. Med., 2016, 10(1): 1-17.
[5] Lunxiu Qin. Osteopontin is a promoter for hepatocellular carcinoma metastasis: a summary of 10 years of studies[J]. Front Med, 2014, 8(1): 24-32.
[6] Meilin Ma, Xiang Wang, Jingyan Tang, Huiliang Xue, Jing Chen, Ci Pan, Hua Jiang, Shuhong Shen. Early T-cell precursor leukemia: a subtype of high risk childhood acute lymphoblastic leukemia[J]. Front Med, 2012, 6(4): 416-420.
[7] Dong KUANG, Guo-Ping WANG, . Hilar cholangiocarcinoma: Pathology and tumor biology[J]. Front. Med., 2010, 4(4): 371-377.
[8] YAN Jiangtao, SHAO Jiaomei, WANG Daowen, YUE Zhengliang, HUI Rutai. Predication of increased plasma homocysteine level on the prognosis of Chinese patients with first-onset ischemic stroke[J]. Front. Med., 2008, 2(4): 352-355.
[9] QIN Lunxiu, TANG Zhaoyou, GUAN Xinyuan, YE Qinghai, JIA Huliang, REN Ning. The predictive value of chromosome 8p deletion for metastasis of hepatocellular carcinoma: a summary of works in 10 years[J]. Front. Med., 2008, 2(3): 211-215.
[10] LIANG Yumei, LI Xianghong, LU Youyong, LV Yali, ZHONG Mei, PU Xiaolu, LI Wenmei. Prognostic significance of clinicopathologic parameters in gastrointestinal stromal tumors: a study of 156 cases[J]. Front. Med., 2008, 2(1): 87-94.
[11] JIANG Yuan, TIAN Xuehong, YUAN Jie, JIN Yuemei, TAN Yusong. Relationship of adrenomedullin expression and microvessel density and prognosis in smooth muscle tumor of uterus[J]. Front. Med., 2007, 1(4): 398-400.
[12] ZHU Wenyu, TAN Liping, CHEN Xiangfeng, HUANG Qiang, LAN Qing. High risk factors for pulmonary fungous infection in intensive care units of neurosurgery[J]. Front. Med., 2007, 1(3): 299-303.
[13] QIN Xinyu, LIU Fenglin. The clinicopathologic features of intraductal papillary mucinous neoplasms of the pancreas[J]. Front. Med., 2007, 1(2): 121-125.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed