What is the diagnosis and treatment for cholangitis without cholecystitis?

From the Guidelines

Cholangitis without cholecystitis requires prompt treatment with broad-spectrum antibiotics and biliary drainage, preferably via endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours, to prevent complications and reduce mortality. The initial management includes broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1. Patients should receive fluid resuscitation and pain management with medications like morphine 2-4mg IV every 4 hours as needed.

Key Considerations

• Biliary decompression is essential and should be performed within 24-48 hours, typically via ERCP with stone removal and/or stent placement, as it has been shown to have lower morbidity and mortality compared to open surgical drainage 1.
• For critically ill patients, urgent ERCP within 24 hours is recommended, as delayed intervention can lead to increased mortality and complications.
• Blood cultures should be obtained before starting antibiotics, and antibiotic therapy should be adjusted based on culture results, typically continuing for 4-7 days total.
• The choice of antibiotic agent should be directed by local practice after taking into consideration the history, severity of liver or renal disease, and bacterial sensitivities, with common first-line agents including fluoroquinolones such as ciprofloxacin or intravenous cephalosporins or extended-spectrum penicillins with anaerobic cover 1.

Biliary Drainage Options

• ERCP is the preferred method for biliary decompression, with various endoscopic transpapillary options available, including biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy 1.
• Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails, due to the potential for significant complications, including biliary peritonitis, hemobilia, pneumothorax, hematoma, liver abscesses, and patient discomfort related to the catheter 1.
• Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed, due to the high mortality rates associated with emergency open operation for severe cholangitis 1.

From the Research

Definition and Causes of Cholangitis

• Cholangitis is a life-threatening infection of the biliary tract, which can be caused by bacterial infections, and can be categorized into different forms such as primary sclerosing cholangitis (PSC), secondary (acute) cholangitis, and IgG4-associated cholangitis (IAC) 2.
• The etiology and pathogenesis of cholangitis are heterogeneous, with roles of genetic and acquired factors noted in the development of various forms of cholangitis 2.

Diagnosis and Treatment of Cholangitis

• Early recognition and treatment of cholangitis in the emergency department is instrumental in ensuring a favorable outcome for patients 3.
• Imaging evaluation of the hepatobiliary system, including endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography, is crucial in the management of cholangitis 2.
• Biliary drainage procedures, such as endoscopic biliary drainage, are necessary for controlling the progression of cholangitis 4, 2.
• Antibiotic therapy is a key component of the treatment of acute cholangitis, with the goal of targeting the most common pathogens 3.
• The American Society for Gastrointestinal Endoscopy (ASGE) suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours 5.

Timing of Intervention

• Emergent biliary drainage within 48 hours is associated with lower in-hospital mortality, 30-day mortality, organ failure, and shorter length of stay in patients with acute cholangitis 6.
• The ASGE suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment 5.

Cholangitis without Cholecystitis

• There is no direct evidence in the provided studies that specifically addresses cholangitis without cholecystitis.
• However, the studies suggest that cholangitis can occur without cholecystitis, and that the treatment and management of cholangitis should be focused on the underlying cause and severity of the disease, rather than the presence or absence of cholecystitis 4, 2, 3, 5, 6.