From the Guidelines
Acute cholangitis requires prompt treatment with antibiotics and biliary drainage, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary decompression in patients with moderate to severe disease 1. The initial management of acute cholangitis includes:
- Fluid resuscitation
- Empiric 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
- Early biliary decompression via ERCP within 24-48 hours 1 Blood cultures should be obtained before starting antibiotics, and antibiotic therapy should be adjusted based on culture results, continuing for at least 4-7 days total. Patients with severe cholangitis presenting with hypotension, altered mental status, or organ dysfunction require ICU admission and more urgent biliary drainage. The condition typically results from biliary obstruction (often due to gallstones, strictures, or tumors) combined with bacterial infection ascending from the intestine. Common pathogens include Escherichia coli, Klebsiella, Enterococcus, and anaerobes. After resolution of the acute episode, addressing the underlying cause is essential to prevent recurrence, which may involve gallstone removal, stent placement, or surgery depending on the etiology 1. Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails, and 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 1. Class A or B patients with acute cholangitis can be managed with ERCP and a short course of antibiotic therapy, while Class C patients require a more multidisciplinary approach with ERCP, antibiotic therapy, and individualized management based on patient condition and risk factors 1.
From the Research
Definition and Causes of Acute Cholangitis
- Acute cholangitis is a life-threatening infection of the biliary tract, resulting from a combination of infection and obstruction of the biliary tree 2, 3, 4, 5, 6.
- Common causes of biliary tree obstruction include choledocholithiasis, benign and malignant biliary strictures 3, 4, 6.
- The infection can be caused by a variety of bacteria, with Escherichia coli and Klebsiella spp. being the main pathogens 6.
Clinical Presentation and Diagnosis
- The clinical presentation of acute cholangitis varies, and initial risk stratification is important to guide further management 3.
- Diagnosis is based on clinical presentation, laboratory data indicating systemic infection, and diagnostic imaging modalities revealing signs of biliary obstruction and possibly an underlying etiology 3, 4, 5, 6.
- Charcot's triad (pain, fever, jaundice) is a classic symptom, but its sensitivity is insufficient, leading to the introduction of a new score validated by the Tokyo Guidelines 6.
- Imaging studies such as abdominal ultrasound, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and CT scan can be used to explore the biliary tract and diagnose acute cholangitis 6.
Treatment and Management
- Early medical therapy, including fluid resuscitation and appropriate antibiotic coverage, is of major importance in all cases 2, 3, 4, 5, 6.
- Biliary drainage procedures such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and open surgical drainage can be used to treat acute cholangitis 3, 4, 6.
- The type and timing of biliary drainage should be based on the severity of the clinical presentation and the availability and feasibility of drainage techniques 3.
- Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes and reduce mortality 2, 4, 5, 6.