From the Guidelines
Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended first-line approach for drainage in acute cholangitis, as it offers both diagnostic and therapeutic capabilities with lower morbidity and mortality rates compared to other options. According to the 2017 WSES guidelines for management of intra-abdominal infections 1, ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis. The guidelines recommend ERCP as the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis (Recommendation 1A) 1.
Key Considerations for Drainage Options
- ERCP is preferred due to its ability to provide both diagnostic and therapeutic capabilities, with success rates of 80-90% 1.
- Percutaneous transhepatic 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.
- Timing of drainage is crucial, with immediate intervention (within 24 hours) recommended for severe cholangitis, while moderate cases can be managed within 48-72 hours.
Pre-Drainage Management
- Patients should receive broad-spectrum antibiotics covering gram-negative and anaerobic bacteria, such as piperacillin-tazobactam 4.5g IV every 6 hours or a combination of ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours.
- Fluid resuscitation and correction of coagulopathy are essential preparatory steps to optimize outcomes and minimize procedure-related complications.
Evidence-Based Recommendations
- A randomized controlled trial (RCT) demonstrated that the morbidity and mortality of endoscopic nasobiliary drainage (ENBD) + endoscopic sphincterotomy (EST) were significantly lower than those of T-tube drainage under laparotomy 1.
- A prospective randomized trial published in 2002 found that endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones 1.
From the Research
Acute Cholangitis Drainage Options
- The primary goal of treatment for acute cholangitis is to relieve the biliary obstruction and drain the infected bile [(2,3,4,5,6)].
- Available drainage options include:
- Endoscopic retrograde cholangiopancreatography (ERCP) [(2,3,5,6)]
- Percutaneous transhepatic cholangiography (PTC) [(2,3,6)]
- Endoscopic ultrasound-guided biliary drainage [(2,3)]
- Open surgical drainage [(2,6)]
- The choice of drainage procedure depends on the severity of the clinical presentation, the availability and feasibility of drainage techniques, and the patient's overall condition [(2,3,6)].
- ERCP is often considered the first-line treatment for biliary obstruction in patients with acute cholangitis [(2,5)].
- Percutaneous biliary drainage (PTBD) is a crucial alternative in select cases, particularly when endoscopic drainage fails or is not possible 3.
- A multidisciplinary approach and early intervention are essential to improving outcomes in acute cholangitis management [(3,4,6)].