What are the clinical presentation and treatment of ascending cholangitis?

From the Guidelines

Approximately 50-90% of ascending cholangitis patients present with Charcot's triad at diagnosis. Ascending cholangitis is a potentially life-threatening infection of the biliary tract characterized by Charcot's triad: fever, right upper quadrant pain, and jaundice. Some patients may develop Reynolds' pentad, which adds hypotension and altered mental status, indicating severe disease. Treatment requires a two-pronged approach: antibiotics and biliary decompression. Initial empiric antibiotic therapy should cover enteric gram-negative organisms and anaerobes, typically using piperacillin-tazobactam 3.375g IV every 6 hours, ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours, or ciprofloxacin 400mg IV every 12 hours plus metronidazole, as recommended by the Tokyo Guidelines 1.

Key Points

• The clinical presentation of ascending cholangitis varies, and initial risk stratification is important to guide further management 1.
• Urgent biliary decompression is necessary within 24-48 hours, usually via endoscopic retrograde cholangiopancreatography (ERCP) with stone removal and/or stent placement, as recommended by the World Journal of Emergency Surgery 1.
• For critically ill patients, immediate decompression is required, and percutaneous transhepatic cholangiography (PTC) or surgical decompression may be alternatives when ERCP is unavailable or unsuccessful.
• Supportive care with IV fluids, pain management, and close monitoring of vital signs is essential, and the underlying cause, commonly gallstones, must be addressed to prevent recurrence.
• Cholangitis develops when biliary obstruction leads to increased pressure, bacterial proliferation, and subsequent translocation into the bloodstream, making prompt intervention crucial for preventing septic shock and death, as highlighted in the BioScience Trends study 1.

Treatment Approach

• Initial empiric antibiotic therapy should cover enteric gram-negative organisms and anaerobes.
• Urgent biliary decompression is necessary within 24-48 hours.
• Supportive care with IV fluids, pain management, and close monitoring of vital signs is essential.
• The underlying cause, commonly gallstones, must be addressed to prevent recurrence, as recommended by the World Journal of Emergency Surgery 1.

Clinical Presentation

• Charcot's triad: fever, right upper quadrant pain, and jaundice.
• Reynolds' pentad: adds hypotension and altered mental status, indicating severe disease.
• The clinical presentation varies, and initial risk stratification is important to guide further management, as highlighted in the World Journal of Emergency Surgery study 1.

From the Research

Clinical Presentation of Ascending Cholangitis

• The clinical presentation of ascending cholangitis is characterized by fever, jaundice, and abdominal pain, known as Charcot's triad 2, 3, 4, 5.
• However, the complete triad is now seen less frequently, with most patients still having leukocytosis and abnormal liver function tests 2.
• The percentage of ascending cholangitis patients who have Charcot's triad at presentation is not explicitly stated in the provided studies.

Treatment of Ascending Cholangitis

• The treatment modalities for ascending cholangitis include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 3, 4, 5.
• Initial therapy includes bowel rest, intravenous fluids, and antibiotics, with many antibiotic regimens available to cover the gram-negative aerobes, the enterococcus, and the anaerobes that are likely to be causing the biliary infection 2.
• The choice of percutaneous or endoscopic drainage should be made on the basis of the presumed site and cause of obstruction as well as local expertise 2.
• Available drainage options include endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, endoscopic ultrasound, and open surgical drainage 5.

Diagnosis of Ascending Cholangitis

• Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 3.
• Abdominal ultrasound quickly explores the biliary tract, but its diagnostic capacities are poor, especially in case of non-gallstone obstruction, as opposed to magnetic resonance cholangiopancreatography and endoscopic ultrasound, of which the diagnostic capacities are excellent 4.
• CT scan is more widely available, with intermediate diagnostic capacities 4.
• Bacteriological sampling through blood cultures and bile cultures is essential, with a wide variety of bacteria involved, but the main pathogens having been found are Escherichia coli and Klebsiella spp. 4.