From the Guidelines
The severity of ascending cholangitis is a critical determinant of treatment approach, with severe cases requiring immediate intervention to prevent mortality rates of up to 10% as reported in the 2016 study by BioScience Trends 1. The severity of ascending cholangitis can be classified into three grades: Grade I (mild), Grade II (moderate), and Grade III (severe).
- Mild cholangitis responds to initial medical treatment including antibiotics such as piperacillin-tazobactam or ciprofloxacin plus metronidazole for 3-5 days.
- Moderate cholangitis presents with signs of systemic inflammation but without organ dysfunction, requiring the same antibiotics plus early biliary drainage within 48-72 hours.
- Severe cholangitis involves organ dysfunction and requires immediate resuscitation, antibiotics, and urgent biliary decompression within 24 hours. The management of biliary stones is still being debated, with both laparoscopic CBD exploration and ERC having similar success rates of stone clearance from the CBD, as reported by BioScience Trends in 2016 1. Endoscopic sphincterotomy and stone extraction have been reported to be successful in more than 90% of cases, with adverse event rates close to 5% and mortality rates < 1%, highlighting the importance of prompt and effective biliary drainage in severe ascending cholangitis 1. The severity assessment guides treatment urgency, with higher grades requiring more aggressive intervention, and prompt recognition of severe cholangitis is crucial as mortality rates can decline to 2.7-10% with effective biliary drainage procedures and potent antibiotic agents, as highlighted in the 2016 study by BioScience Trends 1.
From the Research
Severity of Ascending Cholangitis
The severity of ascending cholangitis can be categorized into different levels, including moderate and severe.
- Moderate acute cholangitis is characterized by the presence of clinical symptoms such as fever, jaundice, and abdominal pain, but without signs of organ dysfunction 2.
- Severe acute cholangitis is defined by the presence of organ dysfunction, such as sepsis, shock, or respiratory failure, in addition to the clinical symptoms of cholangitis 3, 4.
Management of Ascending Cholangitis
The management of ascending cholangitis involves a combination of antibiotic therapy, biliary drainage, and supportive care.
- Antibiotic therapy is essential in the treatment of acute cholangitis, and the choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis 3, 5.
- Biliary drainage is necessary to relieve the obstruction and prevent further infection, and can be achieved through endoscopic, percutaneous, or surgical methods 3, 5, 6.
- Supportive care, such as fluid resuscitation and correction of coagulopathy, is also important in the management of acute cholangitis 3, 4.
Diagnosis and Prognosis of Ascending Cholangitis
The diagnosis of ascending cholangitis is based on clinical features, laboratory tests, and imaging studies.
- Clinical features, such as fever, jaundice, and abdominal pain, are commonly present in patients with acute cholangitis 2, 4.
- Laboratory tests, such as blood cultures and liver function tests, can help confirm the diagnosis and assess the severity of the infection 3, 6.
- Imaging studies, such as ultrasound and computed tomography, can help identify the underlying cause of the biliary obstruction and guide treatment 3, 6.