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Background/Aims: To select appropriate empirical antibiotics, updates on the changes in pathogens are essential. We aimed to investigate the changes in pathogens and their antibiotic susceptibility in acute cholangitis (AC) with bacteremia over a period of 15 years. Furthermore, the efficacy of empirical antibiotic therapies and the risk factors predicting antibiotic-resistant pathogens (ARPs) were analyzed. Methods: A total of 568 patients with AC and bacteremia who were admitted to Daegu Catholic University Medical Center from January 2006 to December 2020 were included. Their medical records were retrospectively reviewed. In addition, the data were grouped and analyzed at 3-year intervals under the criteria of Tokyo Guideline 2018. Results: During the study period, 596 pathogens were isolated from blood cultures of 568 patients. The three most common pathogens were Escherichia coli (50.5%), Klebsiella species (24.5%), and Enterococcus species (8.1%). The proportion of vancomycin-resistant Enterococci (VRE) has increased since the mid-2010 (0.0% to 4.3%, p=0.007). There was emergence of carbapenem-resistant Enterobacteriaceae (CRE) in 2018 to 2020, albeit not statistically significant (1.3%, p=0.096). Risk factors predicting ARP were healthcare-associated infection, history of previous biliary intervention, and the severity of AC. For patients with these aforementioned risk factors, imipenem was the most effective antibiotic and piperacillin-tazobactam was also effective but to a lesser degree (susceptibility rates of 92.1% and 75.0%, respectively). Conclusions: The proportion of VRE has increased and CRE has emerged in AC. In addition, healthcare-associated infection, history of previous biliary intervention, and the severity of AC were independent risk factors predicting ARP. For patients with these risk factors, the administration of imipenem or piperacillin-tazobactam should be considered. [ABSTRACT FROM AUTHOR]

Background/Aims Mass-forming autoimmune pancreatitis may be difficult to differentiate from pancreatic cancer. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) and a steroid trial can be helpful in diagnosis. Here, we report a case of mass-forming autoimmune pancreatitis that was challenging to distinguish from pancreatic head cancer. Case Presentation An 81-year-old male presented with obstructive jaundice and a 2 cm pancreatic head mass. His medical history included hypertension. Before visiting our institution, he had undergone abdominal computed tomography (CT) with contrast enhancement, endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement, and EUS-guided fine needle biopsy (EUS-FNB). Cytology and endobiliary biopsy were negative for malignancy. CT at our institution showed a slight decrease in the pancreatic head mass, raising suspicion of autoimmune pancreatitis. Serum IgG4 was elevated at 1247 mg/L (normal range: 50-1200 mg/L). Antinuclear antibody (ANA) titer was 1:40, and carbohydrate antigen 19-9 (CA 19-9) was 5 U/mL (normal range: <37 U/mL). ERCP revealed focal obstruction in the distal bile duct. After cytology and endobiliary biopsy, a new plastic biliary stent was placed, and EUS-FNB was repeated. Pathology showed chronic inflammation, but IgG4 staining was negative. Given the inconclusive results, a 2-week steroid trial with 50 mg of oral prednisolone was initiated. Prednisolone was tapered by 5 mg every 2 weeks. Follow-up CT revealed a decreased size of the pancreatic mass to 1.3 cm. Follow-up ERCP showed improved bile duct obstruction, eliminating the need for the stent. A subsequent CT after 2 months confirmed further reduction in the pancreatic mass. The patient remains asymptomatic and is on a maintenance dose of 5 mg prednisolone. Conclusion This case underscores the challenge of differentiating mass-forming autoimmune pancreatitis from pancreatic cancer. [ABSTRACT FROM AUTHOR]

Background/Aims The aim of this study was to determine the optimal timing to discontinue endoscopic retrograde cholangiopancreatography (ERCP) when selective biliary cannulation (SBC) is difficult to achieve. Methods Patients with naïve papilla who underwent ERCP between January 2021 and December 2021 were analyzed. The data used in this study were derived from our previously published study in 2024. For this analysis, the entire original dataset was used, including cases that were excluded in the previous study. Patients with acute pancreatitis or elevated serum amylase (greater than 3-fold) prior to ERCP were excluded from the complication analysis, leaving 238 patients for the assessment of complications. The primary outcome was to determine the optimal timing for discontinuing ERCP based on cannulation success rate and complication rate. Results A total of 272 patients with naive papilla underwent ERCP. The trainees did not participate in any of the procedures. The median age was 71 years, and 152 patients (55.9%) were male. The most common indication for ERCP was choledocholithiasis (60.7%), followed by malignant obstruction (24.3%), and benign stricture (4.8%). SBC was successfully achieved in 249 patients (91.5%). 16 patients experienced complications (6.7%), with post-ERCP pancreatitis (PEP) developing in 14 patients (5.9%). During the procedure, 50% of SBC was achieved after 3.3 minutes, and 90% of SBC was achieved after 12.1 minutes (Figure 1). In contrast, the PEP rate reached 9.9% after 7.4 minutes and 15.3 % after 8.8 minutes (Figure 2). Conclusion If SBC is not achieved within 8 minutes after starting ERCP, it is advisable to consider stopping the procedure due to the risk of PEP. Furthermore, if SBC is not successful after 12 minutes, the likelihood of achieving it with further attempts is low. [ABSTRACT FROM AUTHOR]