Acute and Chronic Inflammation of the Biliary System.

Abstract

Acute and chronic inflammatory biliary tract disease has ever since been in the vanguard of gastrointestinal medicine at the interface between surgical and medical care. Likewise, biliary system disorders demand the cooperation between high-volume specialized and community-based patient care, ranging from standard cholecystectomy over personalized assessment of bile duct strictures to liver transplantation for chronic cholestatic liver diseases. In this sense, inflammatory biliary diseases represent a timeless but vital topic forming the overarching theme of the current edition of VISZERALMEDIZIN to which we as Guest Editors warmly welcome you. In this issue old acquaintances will be revisited and new ones be met – such as the emerging topic of the biliary mucosal barrier and the microbiome. This fascinating, novel topic, though still in its infancy, will be introduced by Verdier, Luedde and Sellge [1] from Aachen. Contrary to the paradigm of a sterile biliary milieu under healthy conditions, new data suggest a complex commensal colonization as well as specialized defence and tolerance mechanisms within the biliary system. The impact of this biliary mucosal barrier on chronic hepatobiliary diseases has to be substantiated further in the future. Schuld and Glanemann [2], Homburg, present a state-of-the-art update on the management of acute cholecystitis, representing one of the most common emergencies in visceral medicine. In contrast to the die-hards of hard rock still touring around the world, the recent ACDC trial has set a general standard of care with acute cholecystectomy being performed within the first 24 h after hospitalization that has been embraced and specified by interdisciplinary guidelines. Zimmer and Lammert [3] from Homburg present an update on the mostly endoscopic management of acute bacterial cholangitis and put adequate diagnosis including imaging microbiology and timing as well as modalities of biliary drainage into perspective. Primary sclerosing cholangitis (PSC) as a chronic fibro-obliterative disease of the larger bile ducts is the remaining ‘black box’ of hepatology. For this highly cancer-prone disease of unknown aetiology, there are neither sufficient diagnostic tools nor treatment options available. Reasonable suggestions for patient care by experts in the field are presented by Ehlken and Schramm [4] from one of the centres providing excellent care for PSC in Hamburg. Remaining in the same topical corner, Kirchner and Ruemmele [5] from Regensburg have pioneered the emerging role of sclerosing cholangitis in critically ill patients (SC-CIP), representing a subgroup of secondary sclerosing cholangitis (SSC). Considering that full-blown SC-CIP tends to be progressive with patients requiring liver transplantation, the characterization of patient populations at particular risk represents a clinically relevant research topic. Besides SCC, immunoglobulin G4-associated cholangiopathy has attracted much attention in recent years. While the chronic inflammatory disease may mimic several biliary or pancreatic cancer as well as PSC, it stands out for its reversibility by anti-inflammatory corticosteroids. Therefore, the diagnosis of this disease is critical, and strategies as well as new tools are presented by Hubers and Beuers [6] from Amsterdam. Coming to the last two contributions, the surgeons enter the arena with Bartsch, Heinrich and Lang [7] from Mainz discussing the current limits of surgical resection for bile duct cancer. This topic is critical given the fact that these patients present at a later stage and higher age with comorbidities. Notwithstanding these intricacies, the assessment of resectability of bile duct cancer should be performed by highly specialized hepatobiliary surgeons and communicated with confidence to improve the outcomes for this highly difficult-to-treat tumour. Last but not least, Neumann and colleagues [8], Aachen, discuss the current status of liver transplantation for patients suffering from cholestatic liver diseases. Although this topic has come a long way from being one of the most common indications for liver transplantation two decades ago to a less common one nowadays, controversial issues still remain, in particular related to organ allocation, surgical reconstruction, and disease recurrence. At this stage, we believe that we might have come full circle by now from community to centre and from surgery to gastrointestinal medicine and vice versa. In this sense, we hope that all of you find novel ideas and clinical concepts for your day-to-day care of patients suffering from acute or chronic inflammatory diseases of the biliary system.