January 05, 2006

Question

What is the recommendation for sepsis following biliary stenting?

Response From the Expert

John Baillie, MD, MB, ChB, FRCP 
Professor, Wake Forest University Medical Center and Health Sciences, Winston-Salem, North Carolina; Director, Hepatobiliary and Pancreatic Disorders Service, Baptist Medical Center, Winston-Salem, North Carolina

 

Biliary infection (cholangitis), typically manifest by fever, right upper quadrant abdominal pain, and jaundice (Charcot's triad) following placement of a biliary endoprosthesis, almost always indicates stent malfunction.[1] Possible causes of stent failure include occlusion of the lumen by debris, stone fragments or blood clots, proximal or distal migration of the stent, and kinking of the stent at the time of placement, among others. Cholangitis following biliary stent placement is a frequent cause of early repeat endoscopic retrograde cholangiopancreatography (ERCP), often with removal of the old stent and replacement with a new one. Over the years, antibiotic therapy has been suggested as a strategy for preventing occlusion of biliary stents. When the bile duct is to be instrumented in the presence of a known or suspected biliary obstruction, broad-spectrum prophylactic antibiotics should be administered before, during, and after the ERCP. Unfortunately, a long course of prophylactic antibiotic therapy does not prevent the formation of stones.[2] Alcoholics who need ERCP not infrequently have strictures of the bile duct requiring stenting. Such patients are often poorly compliant, contributing to the statistics for stent occlusion and to the complications associated with the procedure.[3]

Metal mesh biliary stents are said to occlude less frequently than plastic stents. However, they are not immune to occlusion, either from biliary sludge, epithelialization, or tumor ingrowth. Ingrowth is almost abolished with covered metal stents, but these stents can still occlude with biliary sludge. It is usually not a difficult job to clean out an obstructed metal mesh stent, but the internal diameter of plastic endoprostheses is small enough to make cleaning problematic. It is usually quicker and easier just to remove the stent and place a new one. If there is concern about the endoscopist's ability to reaccess the biliary tree after plastic stent extraction, the Soehendra stent extractor (Cook Medical, Inc; Winston-Salem, North Carolina) can be used over a guidewire to maintain access. When endoscopic biliary access is lost, the next step is usually percutaneous, often employing an internal-external drain. Nasobiliary drains are helpful when active sepsis is appreciated during the procedure (eg, pus coming out of the papilla ). Recurrent biliary sepsis is often beyond endoscopic management, and at that point, multidisciplinary discussion and a plan for the next step is required. Surgical diversion of the bile duct may be needed to resolve the problem. Sometimes transient stent occlusion will correct itself, resulting in rapid resolution of obstruction/cholangitis. Whatever the underlying problem, sepsis following biliary stent placement is typically a call to action, with subsequent endoscopic, radiologic, or surgical management likely. In one published series,[4] however, endoscopic and radiologic interventions were the leading causes of severe cholangitis in a tertiary center.

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