What is the diagnosis and treatment for ascending cholangitis?

From the Guidelines

Ascending cholangitis requires immediate medical attention with hospitalization for intravenous antibiotics and urgent biliary decompression through endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours to reduce morbidity and mortality. The treatment involves a combination of a beta-lactam (such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily) plus metronidazole 500mg IV every 8 hours to cover gram-negative and anaerobic organisms 1. Fluid resuscitation and pain management are essential supportive measures.

Key Considerations

• The underlying cause, usually a biliary obstruction from gallstones, tumors, or strictures, must be addressed through ERCP to decompress the biliary system 1.
• In severe cases with septic shock, intensive care monitoring and vasopressor support may be necessary.
• Patients typically require 7-10 days of antibiotics, transitioning to oral therapy once clinically improved.
• The classic presentation includes Charcot's triad (fever, right upper quadrant pain, and jaundice), though not all patients exhibit all symptoms.

Biliary Decompression

• ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, and is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis (Recommendation 1A) 1.
• Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails (Recommendation 1B) 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 (Recommendation 2C) 1.

Antibiotic Therapy

• Biliary infections are often polymicrobial, but the most common organisms are Eschericia coli, Klebsiella, Enterococcus, Clostridium, Steptococcus, Pseudomonas and Bacteroides species 1.
• 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 1.
• A common first-line agent for mild episodes is a fluoroquinolone such as ciprofloxacin, while more severe cases are usually treated with intravenous cephalosporins or extended spectrum penicillins with the addition of anaerobic cover 1.

From the Research

Definition and Causes of Ascending Cholangitis

• Ascending cholangitis, also known as acute cholangitis, is a life-threatening systemic condition that results from a biliary tree infection and obstruction 2, 3.
• Common causes of biliary tree obstruction include choledocholithiasis, benign and malignant biliary strictures 2.
• The etiology and pathogenesis of cholangitis are heterogeneous, with bacterial infections being the most common cause for acute cholangitis 4.

Diagnosis of Ascending Cholangitis

• Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 3.
• The Tokyo Guidelines emphasize the importance of clinical presentation, laboratory blood results, and diagnostic imaging in the diagnosis of acute cholangitis 2.
• Imaging evaluation of the hepatobiliary system, including endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography, is crucial in the management of cholangitis 4.

Treatment and Management of Ascending Cholangitis

• Treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 3.
• Biliary drainage procedures, such as endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and endoscopic ultrasound, are necessary for controlling the progression of cholangitis 2, 4.
• Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis, with the Tokyo Guidelines 2018 providing recommendations for the appropriate use of antimicrobials 5.
• Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes and reduce mortality and morbidity 2, 3.