What is the treatment for ascending cholangitis?

From the Guidelines

The treatment for ascending cholangitis requires prompt intervention with antibiotics and biliary drainage, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary decompression in patients with moderate to severe disease 1. The initial management includes broad-spectrum antibiotics such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole, which target common biliary pathogens including E. coli, Klebsiella, Enterococcus, and anaerobes. Key elements of therapy include:

• Adequate antimicrobial treatment to avoid or manage septic complications
• Biliary decompression to restore biliary drainage in case of obstruction Fluid resuscitation and correction of electrolyte imbalances are essential supportive measures. Definitive treatment requires biliary decompression, typically performed via ERCP within 24-48 hours of presentation, as it has been shown to have lower morbidity and mortality compared to open surgical drainage 1. In cases where ERCP is not feasible, percutaneous transhepatic cholangiography (PTC) may be considered, although it is associated with significant complications, including biliary peritonitis, hemobilia, and pneumothorax 1. Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1. Patients with severe cholangitis presenting with hypotension or altered mental status require intensive care monitoring. Following resolution of the acute episode, addressing the underlying cause, such as cholecystectomy for gallstone disease, is crucial to prevent recurrence. Antibiotic therapy typically continues for 4-7 days total, though can be shorter if source control is achieved promptly. The choice of biliary drainage method should be based on the severity of the clinical presentation and the availability and feasibility of drainage techniques, with ERCP being the central role in the management of biliary obstruction in patients with acute cholangitis 1.

From the Research

Treatment Overview

The treatment for ascending cholangitis involves a combination of supportive care, antibiotics, and biliary decompression. The main goals of treatment are to manage the infection, relieve the obstruction, and prevent further complications.

Supportive Care

• Adequate hydration is essential to help manage the infection and prevent dehydration 2, 3.
• Patients may also require supportive care such as pain management and monitoring of vital signs.

Antibiotic Therapy

• Broad-spectrum antibiotics are recommended to cover common organisms such as Escherichia coli, Klebsiella, Enterococcus, and Enterobacter species 2, 4, 3.
• Antibiotics should be given for 7-10 days in therapeutic dosages 4.
• The choice of antibiotics should reflect local resistance patterns and avoid the overuse of broad-spectrum agents 5.
• In patients with severe disease or those who are critically ill, additional coverage for pathogens such as Bacteroides, Pseudomonas, and yeast may be necessary 3.

Biliary Decompression

• Biliary decompression is a crucial step in the treatment of ascending cholangitis and should be performed early in the course of the illness 2, 3.
• Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and bile fluid culture is a common method of biliary decompression 2.
• Urgent decompression with a percutaneous or endoscopic stent is preferred over operative decompression in most cases 3.

Special Considerations

• Early recognition of the offending organism is critical in guiding therapy, and clinicians should be aware of the possibility of less common pathogens such as Methicillin-resistant Staphylococcus aureus (MRSA) 2.
• Patients with a compromised biliary system, such as those with an endoprosthesis in situ or hepaticojejunostomy, may benefit from antibiotic maintenance therapy to prevent recurrent bouts of cholangitis 4.
• The use of microbiological and patient data can help guide the choice of empirical antibiotic therapy in acute cholangitis 5.