title: Direct biliary drainage using transnasal endoscopy for patients with severe-to-moderate acute cholangitis.
abstract: OBJECTIVE
  Endoscopic biliary drainage (BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy (TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy (ES) previously.
  
  
  METHODS
  Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5-Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated.
  
  
  RESULTS
  A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred.
  
  
  CONCLUSIONS
  Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously.
authors.affiliation: Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Seoul, Korea.
authors.forename: Yun Nah
authors.initials: YN
authors.lastname: Lee
authors.forename: Jong Ho
authors.initials: JH
authors.lastname: Moon
authors.forename: Hyun Jong
authors.initials: HJ
authors.lastname: Choi
authors.forename: Dong Choon
authors.initials: DC
authors.lastname: Kim
authors.forename: Jong Ho
authors.initials: JH
authors.lastname: Chung
authors.forename: Tae Hoon
authors.initials: TH
authors.lastname: Lee
authors.forename: Sang-Woo
authors.initials: SW
authors.lastname: Cha
authors.forename: Young Deok
authors.initials: YD
authors.lastname: Cho
authors.forename: Sang-Heum
authors.initials: SH
authors.lastname: Park
authors.forename: Sun-Joo
authors.initials: SJ
authors.lastname: Kim
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts; D002761:Cholangitis / Q000601:surgery / Q000628:therapy*; D016638:Critical Illness; D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D004724:Endoscopy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009296:Nasal Cavity; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic; D016896:Treatment Outcome