Mazen O. Al-Qadi

Early biliary drainage is associated with favourable outcomes in critically-ill patients with acute cholangitis

Introduction Acute cholangitis (AC) is a clinical condition that requires prompt medical management with IV fluids, antibiotics, and biliary drainage (BD). The optimal timing for BD remains unclear. Aim To investigate the effect of biliary drainage timing on clinical outcomes in AC. Material and methods We conducted a retrospective study of patients with AC admitted to the ICU using the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Emergency department to BD time, hospital death, length of stay (LOS), and severity scores were extracted from the database. We investigated the effect of BD timing on mortality rates, persistent organ failure, and LOS. Results A total of 177 patients were included; 50% were males; median age was 75 years, in-hospital mortality was 9.6%, mean time-to-ERCP was 32 h (range: 0.42–229.6) with 76% meeting the Tokyo Guidelines (TG13) criteria for severe cholangitis, and median Simplified Acute Physiology Score II (SAPS II) was 42 (IQR: 33–51). Using 24 h as a cut-off, patients who underwent BD ≤ 24 h had less persistent organ failure (OR = 0.49; 95% CI: 0.26–0.96, p = 0.040), shorter ICU LOS (3.25 vs. 4.95 days, p = 0.040), shorter hospital LOS (7.71 vs. 13.57 days, p = 0.001), but no difference in either in-hospital mortality (OR = 0.47, 95% CI: 0.17–1.29, p = 0.146) or 28-day mortality (OR = 0.61, 95% CI: 0.24–1.53, p = 0.297). Conclusions In critically-ill patients with acute cholangitis, early biliary drainage ≤ 24 h is associated with less persistent organ failure and shorter length of stay but had no effect on patient survival.

Chronic Pulmonary Aspergillosis Complicating Bronchial Atresia

Bronchial atresia is a rare pulmonary developmental anomaly characterized by the presence of a focal obliteration of a segmental or lobar bronchial lumen. The lung distal to the atretic bronchus is typically emphysematous along with the presence of mucus filled ectatic bronchi (mucoceles). BA is usually asymptomatic but pulmonary infections can rarely develop in the emphysematous lung distal to the atretic bronchus. We present a unique case of chronic pulmonary aspergillosis (CPA) in a patient with BA with no evidence of immune dysfunction. The patient was treated initially with voriconazole and subsequently underwent surgical excision of the involved area. On follow-up, she has done extremely well with no evidence for recurrence. In summary, we describe the first case of chronic pulmonary aspergillosis in an immunocompetent patient with bronchial atresia.