From the Guidelines
Cholangitis is diagnosed using Charcot's triad (fever, right upper quadrant pain, and jaundice) or the more specific Reynolds' pentad, which adds hypotension and altered mental status, and treatment requires a two-pronged approach: antibiotics and biliary drainage, as recommended by the most recent guidelines 1. The diagnostic criteria for cholangitis include laboratory findings such as elevated white blood cell count, liver enzymes (particularly alkaline phosphatase and gamma-glutamyl transferase), and bilirubin levels. Imaging studies like ultrasound, CT scan, or MRCP are essential to identify biliary obstruction, while blood cultures should be obtained before starting antibiotics 1. Some key points to consider in the diagnosis and treatment of cholangitis include:
- The use of MRCP as a non-invasive diagnostic tool to identify biliary obstruction and strictures 1
- The importance of urgent biliary decompression within 24-48 hours, usually via ERCP with stone removal and/or stent placement 1
- The selection of antibiotics with a broad range of antimicrobial activity and good penetration into the bile ducts, such as third-generation cephalosporins, ureidopenicillins, carbapenems, and fluoroquinolones 1
- The need for supportive care with IV fluids, pain management, and close monitoring for sepsis, as well as addressing the underlying cause of obstruction to prevent recurrence 1 It is essential to note that the definition and diagnosis of acute cholangitis in PSC can be challenging, and standard definitions may not be universally applicable 1. Therefore, a thorough evaluation and individualized approach are necessary for each patient. The treatment of cholangitis should prioritize the use of antibiotics and biliary drainage, with a focus on improving quality of life and preventing recurrence, as recommended by the most recent guidelines 1.
From the Research
Diagnostic Criteria for Cholangitis
- The clinical Charcot triad criteria, which include fever, abdominal pain, and jaundice, are commonly used to diagnose acute cholangitis 2, 3, 4.
- The Tokyo Guidelines provide a more comprehensive set of recommendations for the diagnosis and management of acute cholangitis, including the use of laboratory tests and diagnostic imaging 2, 3, 5.
- Laboratory tests, such as blood cultures and bile cultures, can help confirm the diagnosis of acute cholangitis and identify the underlying cause of the infection 3, 6.
- Imaging studies, such as abdominal ultrasound, magnetic resonance cholangiopancreatography, and endoscopic ultrasound, can help visualize the biliary tract and identify any obstructions or other abnormalities 3, 6, 5.
Treatment for Cholangitis
- Antibiotic therapy is a crucial component of treatment for acute cholangitis, with third-generation cephalosporins being a common first-line treatment 3, 4.
- Biliary drainage, either through endoscopic or radiological means, is also essential for treating the underlying obstruction and preventing further complications 2, 3, 5.
- Supportive care, such as intravenous fluids and pain management, may also be necessary to manage symptoms and prevent complications 4, 5.
- In some cases, surgical intervention may be necessary to treat underlying conditions, such as choledocholithiasis or biliary strictures 6, 5.