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 risk stratification is crucial to guide further management, and the key elements of therapy include adequate antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction 1.

Typical Presentation

The typical presentation of ascending cholangitis includes:

• Right upper quadrant pain
• Jaundice
• Fever with chills
• Some patients may also develop hypotension and altered mental status (Reynolds' pentad), indicating severe disease

Management

Management of ascending cholangitis requires:

• Prompt antibiotic therapy to 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
• Biliary decompression via ERCP, which allows for stone removal and stent placement, within 24-48 hours 1
• Percutaneous transhepatic cholangiography (PTC) or surgical decompression are alternatives when ERCP is unavailable or unsuccessful 1
• Supportive care with IV fluids, pain management, and close monitoring of vital signs is essential
• The underlying cause, commonly gallstones, must be addressed to prevent recurrence

Biliary Decompression

Biliary decompression is a critical component of management, and ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 1. 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 ERCP, PTC, and open surgical drainage 1. Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones 1.

From the Research

Typical Presentation of Ascending Cholangitis

• The typical presentation of ascending cholangitis includes fever, jaundice, and right upper quadrant pain, as seen in 95%, 86%, and 67% of patients, respectively 2.
• Other symptoms may include epigastric abdominal pain, low-grade fever, dark urine, and nausea 3.
• The infection is usually caused by bacterial obstruction of the biliary system, with common organisms including Escherichia Coli, Klebsiella, Enterococcus species, and Enterobacter species 3, 4.

Management of Ascending Cholangitis

• The mainstay of therapy for ascending cholangitis is adequate hydration, antibiotics, and biliary decompression 3, 5, 4.
• Broad-spectrum antibiotics should be used to cover common pathogens, including E.coli, Klebsiella sp., Enterococcus sp., and in severely critically ill patients, 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, usually within 72 hours, and can be achieved through percutaneous or endoscopic stent placement or surgical decompression 2, 4.
• Antibiotic therapy should be given for 7-10 days in therapeutic dosages, and may allow a more selective timing of further interventions 6.