Endoscopic biliary drainage is an established mode of treatment for acute cholangitis, having high success rates and low morbidity and mortality [6-8]. Recent advances in and utilization of endoscopic biliary tract drainage along with the administration of antimicrobial agents have contributed to a decrease in the number of deaths due to acute cholangitis. However, it remains a life-threatening disease unless biliary tract drainage is performed in a timely manner.
By univariate analysis, patients who developed cholangitis requiring emergent drainage were more likely to have dilated CBD (> 10 mm) at the first visit than were those who did not (P = 0.025) ( Table 5 ). By multivariate analysis too, CBD dilation was the only significant risk factor for the development of moderate or severe cholangitis among patients with silent bile duct stones (OR = 10.18, 95% CI: 1.09-94.73, P = 0.042) ( Table 6 ).
Between December 2010 and December 2012, 101 consecutive patients with CBD stones underwent ERCP to remove stones or perform biliary drainage at Wakayama Medical University Hospital. The patients included those with and without cholangitis at the time of the endoscopic procedure. In addition, the endoscopic procedure for those patients was performed at various timings such as emergently at the first visit with serious cholangitis, electively due to silent stones and emergently during the waiting period for an elective procedure due to occurrence of cholangitis. The status of the patients and the timings of the endoscopic procedures are summarized in Figure 1 .
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Treatment options for common bile duct stones (CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave lithotripsy).
Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?
At repeat ERCP the pigtail stent was removed and the cholangiogram shows no evidence of calculi with satisfactory drainage from the common bile duct.
Extracorporeal shock wave lithotripsy (ESWL) was investigated initially for treatment of gallbladder stones, but a high stone recurrence rate has limited its use in this condition. 5 In recent years high energy ESWL has been used with more promising results in high risk patients with common bile duct stones.