Sclerosing cholangitis in critically ill patients is a newly described entity of severe biliary disease with progression to liver cirrhosis.
The mechanisms leading to this form of cholangiopathy with stricture formation and complete obliteration of bile ducts are unknown.
In the last 2 years, sclerosing cholangitis was diagnosed in 26 patients during or after their stay on the intensive care unit by ERCP and/or liver histology.
Dr Cornelia Gelbmann and colleagues from Germany evaluated the patho-mechanisms leading to sclerosing cholangitis in critically ill patients.
|All patients suffered severe respiratory insufficiency |
|The American Journal of Gastroenterology |
Complete patient records were available for 17 patients.
Histological evaluations of liver biopsies and of 4 explanted livers, parameters of cardiovascular and respiratory conditions, treatment modalities, and accompanying infections were analyzed.
With the beginning of cholestasis, the earliest endoscopic findings were intrahepatic biliary casts with impairment of the biliary flow and subsequent biliary infection, in most cases with Enterococcus faecium.
Liver biopsy confirmed cholangitis and histology of explanted livers revealed ulcerated biliary epithelium with hemorrhagic exudates in the bile ducts.
In the further course, the team observed progressive sclerosis with formation of multiple strictures of the bile ducts.
All patients suffered severe respiratory insufficiency with the need for mechanical ventilation.
The PaO2/FiO2 ratio until beginning of cholestasis was 151.
The team noted that half of the patients were treated with high-frequency oscillatory ventilation.
Most patients were treated by intermittent prone positioning.
The research team found that all patients required catecholamines for hemodynamic stabilization.
Dr Gelbmann's team concluded, "Secondary sclerosing cholagitis is a severe and in most cases rapidly progressive complication of intensive care patients."
"Ischemic injury of the biliary tree with the formation of biliary casts and subsequent ongoing biliary infection due to multiresistant bacteria seem to be major pathogenic mechanisms in the development of this new entity of sclerosing cholangitis."