Dr. Ally
Clinical question: What impact does procalcitonin have on the management of acute cholangitis?
Background: Procalcitonin has been used to predict disease severity that may lead to septic shock, though this remains a debatable topic. Acute cholangitis portended high morbidity and mortality prior to biliary decompression and enhanced critical care. Severe acute cholangitis is defined by one of these characteristics: cardiovascular dysfunction (such as hypotension requiring dopamine or norepinephrine infusion); neurologic dysfunction (disturbance of consciousness); respiratory dysfunction (PaO2/FiO2 ratio < 300); renal dysfunction (with oliguria or serum creatinine >2 mg/dL); hepatic dysfunction (INR >1.5); or hematological dysfunction (platelet count <100,000/mm3). The Tokyo Guidelines 2018 address acute cholangitis severity by using procalcitonin as a prognostic lab. However, the guidelines highlight the low quality of existing evidence and the need for more research on this topic.
Study design: Systematic scoping review article
Setting: National and international peer-reviewed articles, randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, and case series in adult patients
Synopsis: The researchers searched MEDLINE, EMBASE, and Google Scholar for articles discussing procalcitonin and its relationship to the management of acute cholangitis. They reviewed articles from the origin of these medical databases to July 2021. The inclusion criteria were articles that discussed the effect of procalcitonin on either the severity of acute cholangitis or the indication to perform biliary decompression in adult patients. The exclusion criteria were qualitative studies, review articles, case reports, commentaries, conference abstracts, and studies with pediatric or obstetric patients. With the inclusion and exclusion criteria in mind, the number of records reviewed was filtered down from 1,987 articles to six studies. These were single-center studies in Asia (four from Japan, one from South Korea, and one from China) with five being retrospective case-control and one being prospective case-control. These studies had small sample sizes (n=28 to n=213). All six studies showed that patients with severe acute cholangitis had higher procalcitonin levels (with cut-off values ranging from 1.76 ng/mL to 3.1 ng/mL) but the median procalcitonin level was variable. Only three studies mentioned when biliary decompression was performed, but did not indicate which procalcitonin levels were used to determine the need for urgent biliary decompression. There was variability in the timing of urgent or emergent biliary decompression. Four studies had blood cultures as an endpoint as well. The etiologies of acute cholangitis included choledocholithiasis (most common), cholangiocarcinoma, chronic pancreatitis, pancreatic head cancer, and gall bladder cancer with bile duct invasion. Hospitalists should continue their usual approach when managing patients with acute cholangitis. Serum procalcitonin may be useful to differentiate an infection, such as acute cholangitis, from malignancy, but its use for prognostication of disease severity for patients with acute cholangitis and as a tool to determine when biliary decompression takes place requires more research on this topic.
Bottom line: The use of serum procalcitonin to predict the severity of acute cholangitis and to triage which patients would benefit from urgent biliary decompression requires additional studies to validate it as a prognostic tool.
Citation: Silangcruz K, et al. Procalcitonin to predict severity of acute cholangitis and need for urgent biliary decompression: systematic scoping review. J Clin Med. 2022;11(5):1155. doi: 10.3390/jcm11051155.
Dr. Ally is an associate clinical professor of medicine in the division of hospital medicine and a physician advisor at the University of California,
San Diego.