What are the typical presentation and management of ascending cholangitis?

From the Guidelines

Ascending cholangitis typically presents with Charcot's triad: right upper quadrant pain, jaundice, and fever with chills, and management requires prompt antibiotic therapy and biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours. The clinical presentation of ascending cholangitis can vary, but it often includes symptoms such as abdominal pain, jaundice, and fever, with some patients developing more severe symptoms like hypotension and altered mental status (Reynolds' pentad) 1. Initial antibiotics should cover gram-negative organisms and anaerobes, with regimens including piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours 1. For severe cases or healthcare-associated infections, consider adding coverage for resistant organisms with drugs like vancomycin.

Key Management Strategies

• Biliary decompression should be performed within 24-48 hours via ERCP, which allows for stone removal and stent placement 1.
• Percutaneous transhepatic cholangiography (PTC) or surgical decompression may be necessary if ERCP fails or isn't available 1.
• Fluid resuscitation and supportive care are essential, especially in septic patients.
• The underlying cause, commonly gallstones, must be addressed to prevent recurrence.
• Early recognition and intervention are critical as mortality rates increase significantly with delayed treatment, particularly in elderly patients or those with comorbidities 1.

Antibiotic Therapy

• Initial antibiotics should cover gram-negative organisms and anaerobes 1.
• Regimens including piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours are recommended 1.
• For severe cases or healthcare-associated infections, consider adding coverage for resistant organisms with drugs like vancomycin.

Biliary Decompression

• ERCP is the preferred method for biliary decompression in patients with ascending cholangitis 1.
• PTC or surgical decompression may be necessary if ERCP fails or isn't available 1.
• Biliary stent or nasobiliary drain placement above the obstruction site may be performed during ERCP, with stenting having equal effectiveness compared to nasobiliary drainage but improved patient comfort 1.

From the Research

Presentation of Ascending Cholangitis

• Ascending cholangitis, also referred to as acute cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction 2.
• The clinical manifestations of Charcot's triad, i.e., fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice are present in acute cholangitis 3.
• When not all of the components of the triad are present, then a definite diagnosis can be made if laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction are obtained 3.

Management of Ascending Cholangitis

• The treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 2.
• Broad-spectrum antibiotics should include coverage of E.coli, Klebsiella sp., Enterococcus sp., and in severely critically ill patients, coverage of additional pathogens such as Bacteriodes sp., Pseudomonas, and yeast should be considered 4.
• Biliary decompression should be performed early in the course of the illness when the patient has not improved or if they worsen with hydration and antibiotics 4.
• Urgent decompression with a percutaneous or endoscopic stent is preferred over an operative decompression in most institutions 4.
• First-line antimicrobial therapy by a third-generation cephalosporin is justified, given that the main pathogens having been found are Escherichia coli and Klebsiella spp. 5.

Diagnosis and Severity Assessment

• Clinical diagnosis relies on Charcot's triad (pain, fever, jaundice) but the insufficient sensitivity of the latter led to the introduction in 2007 of a new score validated by the Tokyo Guidelines, which includes biological and radiological data 5.
• The severity of acute cholangitis can be classified into three grades, mild (grade I), moderate (grade II), and severe (grade III), on the basis of two clinical factors, the onset of organ dysfunction and the response to the initial medical treatment 3.
• "Severe (grade III)" acute cholangitis is defined as acute cholangitis accompanied by at least one new-onset organ dysfunction 3.
• "Moderate (grade II)" acute cholangitis is defined as acute cholangitis that is unaccompanied by organ dysfunction, but that does not respond to the initial medical treatment, with the clinical manifestations and/or laboratory data not improved 3.
• "Mild (grade I)" acute cholangitis is defined as acute cholangitis that responds to the initial medical treatment, with the clinical findings improved 3.