What are the initial steps in diagnosing and managing cholangitis?

From the Guidelines

The initial steps in diagnosing and managing cholangitis involve prompt recognition of symptoms, rapid diagnostic evaluation, and early intervention, with empiric broad-spectrum antibiotics initiated immediately, typically with piperacillin-tazobactam or alternatives, and biliary decompression performed within 24-48 hours, preferably via ERCP with sphincterotomy and stone extraction or stent placement, as recommended by the most recent guidelines 1.

Diagnosis and Initial Management

Diagnosis begins with identifying the classic Charcot's triad (fever, right upper quadrant pain, and jaundice) or Reynolds' pentad (which adds hypotension and altered mental status). Laboratory tests should include complete blood count, liver function tests, blood cultures, and coagulation studies. Imaging is crucial, with ultrasound as the first-line option, followed by CT scan, MRCP, or ERCP depending on availability and patient condition.

Antibiotic Therapy

Empiric broad-spectrum antibiotics should be initiated immediately, with selection including those with a broad range of antimicrobial activity and good penetration into the bile ducts, such as third-generation cephalosporins, ureidopenicillins, carbapenems, and fluoroquinolones 1.

Biliary Decompression

Biliary decompression is essential and should be performed within 24-48 hours, preferably via ERCP with sphincterotomy and stone extraction or stent placement. For critically ill patients, percutaneous transhepatic biliary drainage may be necessary if ERCP is unavailable, as recommended by recent guidelines 1.

Key Considerations

Early intervention is critical as mortality increases significantly with delayed treatment, particularly in elderly patients or those with comorbidities. The underlying pathophysiology involves biliary obstruction leading to increased pressure, bacterial translocation, and subsequent systemic inflammatory response. Recent guidelines emphasize the importance of source control in emergency general surgery, including adequate antibiotic therapy and biliary decompression for acute cholangitis 1.

From the Research

Initial Steps in Diagnosing Cholangitis

• The diagnosis of cholangitis is based on clinical presentation and laboratory data indicating systemic infection, as well as diagnostic imaging modalities revealing signs of biliary obstruction and possibly an underlying etiology 2, 3, 4.
• Clinical diagnosis relies on Charcot's triad (pain, fever, jaundice), but the insufficient sensitivity of the latter led to the introduction of a new score validated by the Tokyo Guidelines, which includes biological and radiological data 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 3.

Management of Cholangitis

• Early medical therapy, including fluid resuscitation and appropriate antibiotic coverage, is of major importance in all cases, followed by a biliary drainage procedure and, if possible, definitive therapy of the underlying etiology 2, 3, 4.
• 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, such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and open surgical drainage 2.
• ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, and endoscopic ultrasound-guided biliary drainage recently emerged as a possible alternative to PTC for second-line therapy if ERCP fails or is not possible 2, 3.

Classification and Treatment

• Acute cholangitis can be classified as mild, moderate, or severe, and the treatment should be tailored according to the severity of the disease 4.
• The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction 4.
• Promising results have been reported for the role of antibiotic treatment in management of acute cholangitis, and immunosuppressive drugs have also rendered clinical responses in IgG4-associated cholangitis 5.