From the Guidelines
The treatment for cholangitis requires prompt antibiotic therapy and biliary drainage, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary decompression in patients with moderate to severe acute cholangitis. Initial management includes broad-spectrum antibiotics such as piperacillin-tazobactam (3.375g IV every 6 hours), ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), or ciprofloxacin (400mg IV every 12 hours) plus metronidazole, as recommended by the Tokyo Guidelines (TG13) 1. These antibiotics should be started immediately after blood cultures are drawn, without waiting for results. Fluid resuscitation and pain management are also essential components of initial care.
Key Components of Treatment
- Broad-spectrum antibiotics to cover Gram-negative enteric bacteria and enterococci
- Biliary decompression via ERCP, which has been shown to have lower morbidity and mortality rates compared to open surgical drainage 1
- Removal or bypassing of the obstructing stone, stricture, or tumor during ERCP
- Placement of a stent to maintain drainage, if necessary
Alternative Treatment Options
- Percutaneous transhepatic cholangiography (PTC) may be used in cases where ERCP is not feasible, but it is associated with a higher risk of complications 1
- Open surgical drainage is generally reserved for patients who have failed ERCP and PTC, or have contraindications to these procedures 1
Importance of Prompt Treatment
- Cholangitis is a medical emergency that can progress to septic shock with high mortality rates if left untreated
- Prompt antibiotic therapy and biliary drainage are crucial to preventing complications and improving outcomes, as highlighted by the World Journal of Emergency Surgery guidelines 1 and the BioScience Trends review 1
From the Research
Treatment for Cholangitis
The treatment for cholangitis typically involves a combination of the following:
- Antibiotic therapy: Broad-spectrum antibiotics are administered to cover both gram-negative and gram-positive organisms associated with cholangitis 2, 3, 4.
- Fluid resuscitation: Patients with cholangitis often require fluid resuscitation to manage sepsis and prevent organ failure 2, 3.
- Biliary decompression: This can be achieved through endoscopic, percutaneous, or surgical means, depending on the underlying cause and severity of the disease 2, 3, 5.
- Endoscopic drainage: This is now the treatment of choice for patients with choledocholithiasis, and can be performed using various techniques such as endoscopic papillotomy and stone extraction, or the placement of a biliary drainage system 3, 5.
- Surgical intervention: This is typically reserved for patients who do not respond to conservative therapy, or those with underlying conditions that require surgical management 3, 6.
Antibiotic Therapy
The choice of antibiotics should be based on the most common pathogens associated with cholangitis, and should be adjusted according to the results of blood cultures and other diagnostic tests 2, 3, 4. A study published in 1995 found that ciprofloxacin alone was adequate empirical therapy for patients with cholangitis 4.
Biliary Decompression
The timing and choice of biliary decompression vary depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause of the cholangitis 3, 5. The American Society for Gastrointestinal Endoscopy (ASGE) suggests that endoscopic drainage is preferred over percutaneous drainage, and that biliary decompression should be performed within 48 hours of diagnosis 5.
Surgical Intervention
Surgical intervention is typically reserved for patients who do not respond to conservative therapy, or those with underlying conditions that require surgical management 3, 6. A review published in 2017 found that surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed 6.