Hye Kyung Chang, Jung Hye Kyung Chang, Jung Hye Kyung Chang, Jung Hye Kyung Chang, Jung- - -Tak Oh, Seung Hoon Choi, Seok Joo Han Tak Oh, Seung Hoon Choi, Seok Joo Han Tak Oh, Seung Hoon Choi, Seok Joo Han Tak Oh, Seung Hoon Choi, Seok Joo Han Division of Pediatric Surgery, Department of Surgery, Division of Pediatric Surgery, Department of Surgery, Division of Pediatric Surgery, Department of Surgery, Division of Pediatric Surgery, Department of Surgery, Yonsei University College of Medicine Yonsei University College of Medicine Yonsei University College of Medicine Yonsei University College of Medicine Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Intractable Cholangitis in Biliary Atresia Intractable Cholangitis in Biliary Atresia Intractable Cholangitis in Biliary Atresia Intractable Cholangitis in Biliary Atresia
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Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Yonsei University College of MedicineYonsei University College of MedicineYonsei University College of MedicineYonsei University College of Medicine
Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Home Intravenous Antibiotic Treatment for Intractable Cholangitis in Biliary AtresiaIntractable Cholangitis in Biliary AtresiaIntractable Cholangitis in Biliary AtresiaIntractable Cholangitis in Biliary Atresia
- review of the effects and the role of home intravenous antibiotic treatment (HIVA) in 8 patients of post-Kasai intractable cholangitis with
biliary atresia
- suggestion of HIVA as an effective method for management of intractable cholangitis and intrahepatic biliary cysts in post-Kasai patients
Management of intractable cholangitis and intrahepatic biliary cManagement of intractable cholangitis and intrahepatic biliary cManagement of intractable cholangitis and intrahepatic biliary cManagement of intractable cholangitis and intrahepatic biliary cystsystsystsysts
- many surgical or medical trialsto control cholangitis and intrahepatic biliary cysts
- no treatment of choice of intractable cholangitis or intrahepatic biliary cysts
PurposePurposePurposePurpose
retrospective review of medical recordsretrospective review of medical recordsretrospective review of medical recordsretrospective review of medical recordsfor whom
- treated by HIVA for IC after successful Kasai portoenterostomy with BA - from 1998 to 2008- at Severance Hospital and Yongdong Severance Hospital
diagnostic criteria of cholangitisdiagnostic criteria of cholangitisdiagnostic criteria of cholangitisdiagnostic criteria of cholangitis
1)clinical symptoms such as fever, abdominal pain, jaundice or acholic stool2)laboratory data such as hyperbilirubinemia, elevated liver enzyme
or isolation of bacteria on blood culture3)without other fever focus such as upper respiratory tract infection or
urinary tract infection
MethodsMethodsMethodsMethods
diagnostic criteria of intractable cholangitisdiagnostic criteria of intractable cholangitisdiagnostic criteria of intractable cholangitisdiagnostic criteria of intractable cholangitis
recurrent cholangitis unresponsive to conservative managementwith intravenous antibiotics treatment
1)duration of admission for treatment longer than 1 month
2)three times of admission due to cholangitiswith duration between previous discharge and readmission
less than 1 month
detection of intrahepatic biliary cystdetection of intrahepatic biliary cystdetection of intrahepatic biliary cystdetection of intrahepatic biliary cyst
ResultsResultsResultsResultsIntractable cholangitis (IC) after successful Kasai operation
in 10 cases during last decade
to settle IC, intrahepatic cysts were drained in the first two patientsbut IC was not controlled
Intrahepatic cysts in case IIntrahepatic cysts in case IIntrahepatic cysts in case IIntrahepatic cysts in case I Remained intrahepatic cysts after Remained intrahepatic cysts after Remained intrahepatic cysts after Remained intrahepatic cysts after hepatic cystojejunostomy in case Ihepatic cystojejunostomy in case Ihepatic cystojejunostomy in case Ihepatic cystojejunostomy in case I
ResultsResultsResultsResultsHIVA program in the patients diagnosed as ICHIVA program in the patients diagnosed as ICHIVA program in the patients diagnosed as ICHIVA program in the patients diagnosed as IC
after insertion of central venous catheterwith help of home care nursing in 10 cases
two patients of initial period of HIVA were not followed upbecause of transfer to other hospital
Duration of HIVADuration of HIVADuration of HIVADuration of HIVA
from 8 to 39 months with median value of 13.5 months
two patients on HIVAduration of 8 months for one patient and 15 months for the other
six patients off HIVAfrom 8 to 39 months of duration with median value of 14 months
Clinical Characteristics of Patients on HIVAClinical Characteristics of Patients on HIVAClinical Characteristics of Patients on HIVAClinical Characteristics of Patients on HIVA
IC : intractable cholangitisIC : intractable cholangitisIC : intractable cholangitisIC : intractable cholangitisIHC : intrahepatic cystIHC : intrahepatic cystIHC : intrahepatic cystIHC : intrahepatic cystHIVA : home intravenous antibiotic treatmentHIVA : home intravenous antibiotic treatmentHIVA : home intravenous antibiotic treatmentHIVA : home intravenous antibiotic treatment1) Kasai op. at other hospital1) Kasai op. at other hospital1) Kasai op. at other hospital1) Kasai op. at other hospital
Duration of HIVADuration of HIVADuration of HIVADuration of HIVA(months)(months)(months)(months)
Disappearance of IHCDisappearance of IHCDisappearance of IHCDisappearance of IHC1)1)1)1) Duration of Initial Ch.Duration of Initial Ch.Duration of Initial Ch.Duration of Initial Ch.----free Status free Status free Status free Status after HIVA (months)after HIVA (months)after HIVA (months)after HIVA (months)
1111 18181818 YYYY 42424242
2222 16161616 YYYY 13131313
3333 8888 YYYY 13131313
4444 39393939 YYYY 13131313
5555 9999 YYYY 52525252
6666 12121212 YYYY 31313131
7777 15 (on Tx.)15 (on Tx.)15 (on Tx.)15 (on Tx.) ----2)2)2)2) 3333
8888 8 (on Tx.)8 (on Tx.)8 (on Tx.)8 (on Tx.) NNNN 3333
IHC : intrahepatic cystIHC : intrahepatic cystIHC : intrahepatic cystIHC : intrahepatic cystCh. : cholangitisCh. : cholangitisCh. : cholangitisCh. : cholangitis1)1)1)1) detected by imaging studies (abd. U/S or CT)detected by imaging studies (abd. U/S or CT)detected by imaging studies (abd. U/S or CT)detected by imaging studies (abd. U/S or CT)2)2)2)2) no previously detected intrahepatic cystno previously detected intrahepatic cystno previously detected intrahepatic cystno previously detected intrahepatic cyst
1) Admission due to cholangitis1) Admission due to cholangitis1) Admission due to cholangitis1) Admission due to cholangitis2) Duration from diagnosis of intractable cholangitis to HIVA2) Duration from diagnosis of intractable cholangitis to HIVA2) Duration from diagnosis of intractable cholangitis to HIVA2) Duration from diagnosis of intractable cholangitis to HIVA3) Admission days / duration in months3) Admission days / duration in months3) Admission days / duration in months3) Admission days / duration in months4) Duration from HIVA to last follow up4) Duration from HIVA to last follow up4) Duration from HIVA to last follow up4) Duration from HIVA to last follow up5) Admission during HIVA5) Admission during HIVA5) Admission during HIVA5) Admission during HIVA
Effect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to Cholangitis
1) Wilcoxon Signed Ranks Test1) Wilcoxon Signed Ranks Test1) Wilcoxon Signed Ranks Test1) Wilcoxon Signed Ranks Test
Before HIVA Before HIVA Before HIVA Before HIVA After HIVAAfter HIVAAfter HIVAAfter HIVA PPPP----ValueValueValueValue1)1)1)1)
Admission RatioAdmission RatioAdmission RatioAdmission Ratio(Admission days / duration in months) (Admission days / duration in months) (Admission days / duration in months) (Admission days / duration in months)
Effect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to CholangitisEffect of HIVA on Admission Rate due to Cholangitis
Results of HIVAResults of HIVAResults of HIVAResults of HIVA
LongLongLongLong----term Results of HIVAterm Results of HIVAterm Results of HIVAterm Results of HIVA
Duration of Duration of Duration of Duration of FollowFollowFollowFollow----up after up after up after up after HIVA (months)HIVA (months)HIVA (months)HIVA (months)
Ch. on Last Ch. on Last Ch. on Last Ch. on Last FollowFollowFollowFollow----upupupup
Duration of Last Duration of Last Duration of Last Duration of Last Ch.Ch.Ch.Ch.----free Status free Status free Status free Status
after HIVA after HIVA after HIVA after HIVA (months)(months)(months)(months)
Recurrence of Recurrence of Recurrence of Recurrence of IHCIHCIHCIHC1)1)1)1)
Duration of IHCDuration of IHCDuration of IHCDuration of IHC----free Status free Status free Status free Status (months) (months) (months) (months)
T.Bb : serum total bilirubin, Alb : serum albuminT.Bb : serum total bilirubin, Alb : serum albuminT.Bb : serum total bilirubin, Alb : serum albuminT.Bb : serum total bilirubin, Alb : serum albuminPT : prothrombin time, INR : international normalized ratio of PPT : prothrombin time, INR : international normalized ratio of PPT : prothrombin time, INR : international normalized ratio of PPT : prothrombin time, INR : international normalized ratio of PTTTTSm : small amount of ascites, * : detected in U/S or CTSm : small amount of ascites, * : detected in U/S or CTSm : small amount of ascites, * : detected in U/S or CTSm : small amount of ascites, * : detected in U/S or CT
-Intractable cholangitis after successful Kasai portoenterostomy can be controlled by HIVA treatment with statistically significantreduction of admission period due to cholangitis (p=0.012).
-The duration of cholangitis free in HIVA-off group ranged from 12 to 52 months (median value of 29 months).
-Intrahepatic cysts related to intractable cholangitis also can becontrolled and disappeared by HIVA treatment.
- Hepatic function is maintained good in all 8 patients of HIVA.
SummarySummarySummarySummary
ConclusionConclusionConclusionConclusion
-HIVA may be an effective primary treatment for intractablecholangitis after Kasai operation in biliary atresia.
-All of the 8 patients with HIVA for IC have tolerable hepatic function by control of cholangitis and following biliary cirrhosis. No patient required liver transplantation due to chronic liver disease or hepatic failure.
-Early application of HIVA to intractable cholangitis may help tomaintain the hepatic function without recurrence of cholangitis or intrahepatic biliary cysts.
-Early detection of intrahepatic biliary cysts or early diagnosis of intractable cholangitis are necessary for early HIVA application.