Recurrent pyogenic cholangitis is prevalent in Hong Kong and East Asia. While the recent influx of Asian immigrants has resulted in more cases appearing in the West, over the past three decades, the overall incidence in East Asia has been in decline. The experience of the Queen Mary Hospital and other hospitals in the region has been confirmed by comprehensive surveys. The decline in incidence has been attributed to the improved economic situation and living standards with the associated westernisation of diet.published_or_final_versio

Fan, ST

Lo, CM

Wong, J

Hong Kong Medical Journal

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Title The changing epidemiology of recurrent pyogenic cholangitisAuthor(s) Lo, CM; Fan, ST; Wong, JCitation Hong Kong Medical Journal, 1997, v. 3 n. 3, p. 302-304Issued Date 1997URL http://hdl.handle.net/10722/45392Rights Creative Commons: Attribution 3.0 Hong Kong License302      HKMJ Vol 3 No 3 September 1997Lo et alDepartment of Surgery, The University of Hong Kong, Queen MaryHospital, Pokfulam, Hong KongCM Lo, MB, BS, FHKAM (Surgery)ST Fan, MS, FHKAM (Surgery)J Wong, PhD, FHKAM (Surgery)Correspondence to: Dr CM LoIntroductionThe term recurrent pyogenic cholangitis (RPC) wasproposed by Cook in 19541 to describe a disease entitycharacterised by repeated primary infection of thebiliary system by pus-forming bacteria with subsequentformation of multiple stones and strictures in the biliarytree. However, it was Digby who in 1930 first describedthe disease in Hong Kong Chinese.2 In comparing thebiliary calculus disease of Chinese with that inCaucasians, Digby stated “In Chinese patients, as seenin Hong Kong, we find an entirely different clinicalpicture.” The disease came to be known as Hong Kongdisease.3 Further comprehensive studies by Ong4confirmed that, in contrast with Western gallstonedisease, RPC affects a completely different patientpopulation. The condition is prevalent in East Asia andis more common in rural areas. Both men and womenof lower socio-economic class are equally affected,with a peak age incidence in the third and fourthdecades of life.The changing epidemiologyRecurrent pyogenic cholangitis is rare in the Westwhere many of the reported cases have been immi-grants from Asia.3,5 A necropsy study by Lindström6identified only five patients with intrahepatic stonesThe changing epidemiology of recurrent pyogeniccholangitisCM Lo, ST Fan, J WongRecurrent pyogenic cholangitis is prevalent in Hong Kong and East Asia. While the recent influx of Asianimmigrants has resulted in more cases appearing in the West, over the past three decades, the overallincidence in East Asia has been in decline. The experience of the Queen Mary Hospital and other hospitalsin the region has been confirmed by comprehensive surveys. The decline in incidence has been attributedto the improved economic situation and living standards with the associated westernisation of diet.HKMJ 1997;3:302-4Key words: Cholangitis; Biliary tract diseases; Epidemiologic factorsof 804 patients (0.6%) with biliary calculi. As a resultof the recent increased number of Asian immigrantsto the West, the disease is now encountered morefrequently,7 particularly in cities with large Asianpopulations. Glenn and Moody reported, however, thatthe incidence of biliary tract diseases in the offspringof Chinese and Japanese immigrants in the UnitedStates are not different from that found in the popu-lation in general,8 suggesting that environmental, ratherthan ethnic factors, are implicated in the pathogenesisof RPC; thus, the recent increase in RPC can only betransient. By contrast, in East Asia, it is the generalimpression of most clinicians involved with themanagement of this disease that over the past threedecades, the incidence of RPC has been in decline.Individual hospital surveyThe true incidence of RPC is difficult to assess; itsprevalence is usually indicated by the relative incidenceamong all patients with biliary calculi. In the 1960s,RPC was the third most common abdominal surgicalemergency and the most common surgical conditionaffecting the biliary tree present in patients at QueenMary Hospital.9 Over the ensuing three decades,although the number of cases of RPC seen at thehospital has declined slowly, the relative incidenceamong all patients with biliary calculi has decreasedconsiderably. In the original series (from 1950 to 1952)in which Cook first used the term RPC,1 an average of30 patients with RPC were seen each year at the QueenMary Hospital. Fung used the term cholangiohepa-titis10 and reported that 24.2 patients per year were seenin the period 1948 to 1958, accounting for 58% of allpatients with biliary calculi. More recently, Fan andHKMJ Vol 3 No 3 September 1997      303Recurrent pyogenic cholangitiscolleagues reported that from 1984 to 1989, the numberof cases seen at the hospital each year was 22.8, andaccounted for only 12% of all patients with biliarycalculi.11 There are several ways to interpret thischange: (1) given the decreasing number of casesdespite a growing population in Hong Kong, the trueincidence of RPC is decreasing; (2) the decrease inrelative incidence is related to a marked increase ofother cholelithiasis; or (3) the difference is related to achange in the referral pattern of the hospital.The Table shows the most common hepatobiliarydiseases of patients undergoing operation at QueenMary Hospital between January 1994 and December1995. Compared with the report by Fung in 1961,10when RPC was the most common hepatobiliarydisease, RPC is now fourth on the list. Although adifference in referral pattern might be a reason for thischange, a decrease in the true incidence of RPC seemsmore likely. Similarly, other hospitals in the region havealso experienced a fall in the number of cases of RPC.In Taiwan, Chang and Passaro showed that the numberof cases seen at the Tri-Service General Hospitaldecreased by half in the decade after 1974,12 while therelative incidence at the Veterans General Hospital-Taipei decreased marginally from 14% in the 1970s to12% in the 1980s.13Nationwide surveyTaiwan probably has the highest relative incidence ofRPC of all Asian countries. A retrospective survey byNakayama and colleagues,14 from 1976 to 1980,showed that the relative incidence of RPC was 53.5%in Taiwan, much higher than the incidences of Japan,Hong Kong, and Singapore. The Taiwan figure wasreported from Kaohsiung Medical College, which wasthe only major hepatobiliary referring centre insouthern Taiwan. A nationwide cooperative study of17 182 patients with biliary calculi disease from 28medical centres in Taiwan,13 however, showed a loweraverage incidence of 20.0% for the whole of Taiwan,with a decreasing trend most noticeable in the northernpart. From 1981 to 1989, the proportion of patientswith hepatolithiasis decreased from 21.3% to 18.7%while the percentage with gallbladder stones increasedfrom 50.8% to 63.0%. In Japan, a nationwide surveyof 330 institutions in the 1970s revealed 1590 patientswith RPC of 38 606 patients (4.1%) with biliary calculiwho were undergoing operation.15 Compared with thepre-war years, the incidence was decreasing and thedecrease was most marked in urban areas.Changing epidemiology in relation to aetiologyIt is known that RPC predominantly affects the lowersocio-economic class and is more common in ruralrather than urban areas.16,17 Increased wealth andimproved living standards with associated western-isation of diet are thought to be involved in thechanging epidemiology of RPC in Asian countries.With the rapid growth of the per capita national incomein these countries, the improvement of environmentalhygiene and living conditions decreases the chance ofrecurrent enteric infection and portal bacteraemia,which is the main source of the biliary pathogens.4Data on per capita daily nutrient availability in Taiwanin the 1970s and 1980s reveals a trend towards moreprotein and fat and less carbohydrate in the generaldiet.13The traditional Oriental diet containing highcarbohydrate, low protein, and low saturated fat hasbeen incriminated as an important aetiological factorfor RPC. Saturated fat causes cholecystokinin releaseand relaxation of the sphincter of Oddi18 and a dietlow in fat content may lead to a relative increase inbiliary stasis. From animal and human studies, a lowprotein diet is responsible for a decreased bile level ofglucaro-1:4-lactone, which is the leading inhibitor ofbacterial β-glucuronidase,19 the enzyme responsible forthe splitting of bilirubin diglucuronide into insolubleunconjugated bilirubin, thereby forming calciumbilirubinate stones. Thus, the improvement in economicstatus and the consumption of a more Western-stylediet containing more protein and saturated fat may havecontributed to the decreasing incidence of intrahepaticTable. Hepatobiliary diseases of patients under-going operation at Queen Mary Hospital (Jan 1994- Dec 1995)Disease No. of patients (%)Cholelithiasis 216 (44.1)Hepatocellular carcinoma 104 (21.2)Other liver tumours 68 (13.9)Recurrent pyogenic cholangitis 33 (6.7)Carcinoma of the pancreas 22 (4.5)Others 47 (9.6)Total 490304      HKMJ Vol 3 No 3 September 1997Lo et alstones and the concomitant increasing incidence ofcholesterol gallbladder stones.Whether the eradication of parasites such asClonorchis sinensis or Ascaris lumbricoides has beenresponsible for the decline in incidence of RPC remainsdoubtful. Although the endemic areas for these parasiticinfestations correspond to those of RPC,11 theproportion of RPC patients with proven parasiticinfestation does not differ from that of the generalpopulation.4 Despite the low incidence of Clonorchisinfestation in Taiwan, and the virtual eradication ofparasites in Japan in the 1950s, both countries still havea high incidence of RPC.ConclusionBoth individual hospital experience and nationwidesurveys indicate that the incidence of RPC in East Asiais declining. It is difficult to predict whether this trendwill continue. At present, RPC is still a common clinicalproblem in this part of the world as those who havethe disease in their early life continue to present withacute cholangitis, jaundice, portal hypertension, orcholangiocarcinoma. For years to come, clinicians inHong Kong and East Asia will need to be aware of andtreat this potentially lethal biliary tract infection.References1. Cook J, Hou PC, Ho HC, McFadzean AJ. Recurrent pyogeniccholangitis. Br J Surg 1954;42:188-203.2. Digby KH. Common-duct stones of liver origin. Br J Surg1930;17:578-91.3. Mage S, Morel AS. Surgical experience with cholangio-hepatitis (Hong Kong disease) in Canton Chinese. Ann Surg1965;162(2):187-90.4. Ong GB. A study of recurrent pyogenic cholangitis. Arch Surg1962;84:199-225.5. Turner WW, Cramer CR. Recurrent oriental cholangiohepatitis.Surgery 1983;93(3):397-401.6. Lindström CG. Frequency of gallstone disease in a well-definedSwedish population. A prospective necropsy study in Malmö.Scand J Gastroenterol 1977;12:341-6.7. Stain SC, Incarbone R, Guthrie CR, et al. Surgical treatmentof recurrent pyogenic cholangitis. Arch Surg 1995;30:527-33.8. Glenn F, Moody FG. Intrahepatic calculi. Ann Surg 1961;153(5):711-24.9. Stock FE, Fung JH. Oriental cholangiohepatitis. Arch Surg1962;84:409-12.10. Fung J. Liver fluke infestation and cholangio-hepatitis. Br JSurg 1961;48:404-15.11. Fan ST, Choi TK, Lo CM, Mok FP, Lai EC, Wong J. Treatmentof hepatolithiasis: improvement of result by a systematicapproach. Surgery 1991;109(4):474-80.12. Chang TM, Passaro E. Intrahepatic stones: the Taiwanexperience. Am J Surg 1983;146:241-4.13. Su CH, Lui WY, P’eng FK. Relative prevalence of gallstonediseases in Taiwan. A nationwide cooperative study. Dig DisSci 1992;37(5):764-8.14. Nakayama F, Soloway RD, Nakama T, et al. Hepatolithiasis inEast Asia. Retrospective study. Dig Dis Sci 1986;31(1):21-6.15. Nakayama F, Furusawa T, Nakama T. Hepatolithiasis in Japan:present status. Am J Surg 1980;139:216-20.16. Nagase M, Hikasa Y, Soloway RD, Tanimura H, Setoyama M,Kato H. Gallstones in Western Japan. Factors affecting theprevalence of intrahepatic gallstones. Gastroenterology1980;78(4):684-90.17. Wong J, Choi TK. Recurrent pyogenic cholangitis. Dig Surg1986;3:265-75.18. Ashkin JR, Lyon DT, Shull SD, Wagner CI, Soloway RD.Factors affecting delivery of bile to the duodenum in man.Gastroenterology 1978;74:560-5.19. Matsushiro T, Suzuki N, Sato T, Maki T. Effects of diet onglucaric acid concentration in bile and the formation of calciumbilirubinate gallstones. Gastroenterology 1977;72:630-3.

The changing epidemiology of recurrent pyogenic cholangitis

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The changing epidemiology of recurrent pyogenic cholangitis

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