From the Guidelines
The initial treatment plan for acute cholangitis should include prompt administration of broad-spectrum antibiotics, fluid resuscitation, and biliary decompression, with ERCP being the preferred method for biliary decompression, as recommended by the most recent guidelines 1. The key elements of therapy in acute cholangitis are adequate antimicrobial treatment to avoid or manage the septic complications and biliary decompression to restore biliary drainage in case of obstruction 1.
- Empiric antibiotic therapy should be started immediately with regimens 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, or ciprofloxacin 400mg IV every 12 hours plus metronidazole, as these antibiotics target common biliary pathogens including gram-negative organisms (E. coli, Klebsiella) and anaerobes 1.
- Aggressive IV fluid resuscitation with normal saline or lactated Ringer's solution should be provided to correct hypovolemia and electrolyte imbalances.
- Pain management with opioid analgesics may be necessary.
- Biliary decompression should be performed within 24-48 hours, with ERCP being the preferred method to remove obstructing stones or place stents, as it has been shown to have lower morbidity and mortality compared to other methods 1.
- For critically ill patients with septic shock, biliary drainage should be performed urgently.
- Supportive care includes close monitoring of vital signs, urine output, and laboratory values. This comprehensive approach addresses both the infection and the underlying biliary obstruction, which is essential since the combination of increased biliary pressure and bacterial contamination drives the pathophysiology of cholangitis 1.
From the Research
Initial Treatment Plan for Acute Cholangitis
The initial treatment plan for acute cholangitis involves several key components, including:
- Fluid resuscitation to stabilize the patient and prevent dehydration 2, 3, 4
- Correction of coagulopathy to prevent bleeding complications 2
- Administration of broad-spectrum antibiotics to cover both gram-negative and gram-positive organisms associated with cholangitis 2, 5, 3, 6
- Biliary decompression, which may be performed endoscopically, percutaneously, or surgically, depending on the severity of the disease and the patient's response to initial treatment 2, 5, 3, 6
Antibiotic Therapy
The choice of antibiotics should cover the most common pathogens associated with cholangitis, including:
- Escherichia coli
- Klebsiella spp.
- Enterococcus spp.
- Anaerobic infections 6 A third-generation cephalosporin is often recommended as first-line antimicrobial therapy 6
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 2, 5 Endoscopic retrograde cholangiopancreatography (ERCP) plays a central role in the management of biliary obstruction in patients with acute cholangitis 5 Other options for biliary decompression include percutaneous transhepatic cholangiography (PTC) and open surgical drainage 5, 6