From the Guidelines
Cholangitis is a serious infection of the bile ducts that requires prompt medical attention, with symptoms including fever, abdominal pain, jaundice, dark urine, and light-colored stools, and treatment typically involves hospitalization, intravenous antibiotics, and biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours of admission. The diagnosis of acute cholangitis should include clinical signs, laboratory findings, and imaging findings, as stated in the 2024 clinical practice guideline update by the Infectious Diseases Society of America 1.
Symptoms of Cholangitis
- Fever
- Abdominal pain (particularly in the right upper quadrant)
- Jaundice (yellowing of skin and eyes)
- Dark urine
- Light-colored stools
This combination of fever, right upper quadrant pain, and jaundice is known as Charcot's triad and strongly suggests cholangitis.
Treatment of Cholangitis
- Hospitalization
- Intravenous antibiotics such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole, as these target the common bacteria that cause the infection, including E. coli, Klebsiella, and Enterococcus 1
- Fluid resuscitation and pain management
- Biliary drainage is necessary to relieve the obstruction causing the infection, typically performed via ERCP within 24-48 hours of admission 1
- In severe cases where ERCP isn't possible, percutaneous transhepatic cholangiography (PTC) or surgical intervention may be required
- After the acute infection resolves, addressing the underlying cause (such as gallstones, strictures, or tumors) is crucial to prevent recurrence
The 2024 clinical practice guideline update by the Infectious Diseases Society of America on complicated intra-abdominal infections provides the most recent and highest quality evidence for the diagnosis and treatment of cholangitis 1. The guideline emphasizes the importance of clinical signs, laboratory findings, and imaging findings in the diagnosis of acute cholangitis.
In terms of treatment, the guideline recommends hospitalization and intravenous antibiotics, as well as biliary drainage via ERCP within 24-48 hours of admission. The guideline also notes that percutaneous transhepatic cholangiography (PTC) or surgical intervention may be required in severe cases where ERCP isn't possible.
Overall, the treatment of cholangitis requires prompt medical attention and a comprehensive approach that includes hospitalization, intravenous antibiotics, and biliary drainage. The most important step in the treatment of cholangitis is biliary drainage, which should be performed via ERCP within 24-48 hours of admission 1.
From the Research
Symptoms of Cholangitis
- Fever and/or chills
- Abdominal pain (right upper quadrant or epigastric)
- Jaundice 2, 3, 4
- Confusion and septic shock (Reynolds' pentad) 3
- Hypotension, anemia, and severe jaundice 4
Treatment of Cholangitis
- Prompt diagnosis and severity assessment are necessary for appropriate management 2
- Empiric broad-spectrum antibiotic treatment 3, 5, 6
- Timely endoscopic biliary drainage depending on the severity of the disease 3
- Relief of biliary obstruction is mandatory 6
- Emergency invasive therapy is reserved for patients who fail to show a clinical response to antibacterial therapy within the first 36 to 48 hours or for those who deteriorate after an initial clinical improvement 6
- Immediate surgery is indicated for gangrenous cholecystitis and perforation with peritonitis 6
- Long-term administration of antibacterials is required for recurrent cholangitis 6
- Preoperative administration of prophylactic antibacterials can reduce wound infection rates after biliary tract surgery 6
- Antibacterial prophylaxis before endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice 6
Classification of Acute Cholangitis
- Mild (grade I): responds to initial medical treatment, with clinical findings improved 2
- Moderate (grade II): unaccompanied by organ dysfunction, but does not respond to initial medical treatment, with clinical manifestations and/or laboratory data not improved 2
- Severe (grade III): accompanied by at least one new-onset organ dysfunction 2