What is the best next step in managing a patient with suspected ascending cholangitis, presenting with jaundice, fever, right upper quadrant abdominal pain, and biliary ductal dilatation?

From the Guidelines

The best next step in managing a patient with suspected ascending cholangitis is immediate initiation of broad-spectrum intravenous antibiotics, followed by urgent biliary decompression.

Key Considerations

• The patient's presentation with jaundice, fever, right upper quadrant abdominal pain, and biliary ductal dilatation is consistent with ascending cholangitis, a potentially life-threatening condition.
• Empiric antibiotic therapy should include coverage for gram-negative organisms and anaerobes, such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours, as suggested by 1.
• Biliary decompression should be performed within 24-48 hours, typically via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction or stent placement if obstruction is present, as recommended by 1.
• Fluid resuscitation and close monitoring of vital signs are essential supportive measures.

Rationale

• Ascending cholangitis represents a potentially life-threatening condition where bacteria ascend from the duodenum into obstructed bile ducts, causing systemic infection.
• Prompt antibiotic therapy addresses the infectious component while biliary decompression relieves the obstruction that perpetuates the infection, significantly reducing morbidity and mortality, as supported by 1 and 1.
• The EASL-EAGE guidelines suggest dilation of a high-grade stricture if it is regarded as the cause of complications such as bacterial cholangitis, and patients with severe acute cholangitis and high-grade bile duct strictures are at high risk of mortality and require urgent biliary decompression, as stated in 1.

Management

• Start empiric broad-spectrum antibiotics and ensure adequate fluid resuscitation and monitoring.
• Arrange for urgent biliary decompression via ERCP or alternative methods if ERCP is unavailable or unsuccessful.
• Consider the patient's underlying medical conditions, such as type 2 diabetes mellitus and hypertension, when managing their care, as mentioned in the patient's history.
• The use of antibiotics such as third-generation cephalosporins, ureidopenicillins, carbapenems, and fluoroquinolones, which have good penetration into the bile ducts, is supported by 1.

From the FDA Drug Label

ACUTE BACTERIAL OTITIS MEDIA Caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains). SKIN AND SKIN STRUCTURE INFECTIONS Caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii,1Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis1or Peptostreptococcus species INTRA-ABDOMINAL INFECTIONS Caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species.

The best next step in managing a patient with suspected ascending cholangitis is to start empiric broad-spectrum antibiotics.

• The patient's presentation with jaundice, fever, right upper quadrant abdominal pain, and biliary ductal dilatation is consistent with ascending cholangitis, which is a bacterial infection of the biliary tract.
• Broad-spectrum antibiotics, such as ceftriaxone, are effective against a wide range of bacteria that can cause ascending cholangitis, including Escherichia coli, Klebsiella pneumoniae, and Bacteroides fragilis 2, 2.
• It is essential to start antibiotic therapy promptly to prevent complications, such as sepsis and organ failure.
• Additionally, biliary drainage may be necessary to relieve obstruction and prevent further complications.
• However, the provided drug labels do not directly address the need for biliary drainage or other specific treatments for ascending cholangitis.

From the Research

Diagnosis and Management of Acute Cholangitis

The patient's presentation with jaundice, fever, right upper quadrant abdominal pain, and biliary ductal dilatation is suggestive of acute cholangitis. The management of this condition involves:

• Broad-spectrum antibiotics to cover gram-negative aerobic enteric organisms, gram-positive Enterococcus, and anaerobic bacteria 3
• Biliary decompression, which is the mainstay of therapy, to be performed early in the course of the illness when the patient has not improved or if they worsen with hydration and antibiotics 3, 4
• Supportive care with hydration and close monitoring of vital signs for determination of potential septicemia 3, 4

Choice of Next Step

Given the patient's presentation and the need for urgent biliary decompression, the best next step would be:

• Order endoscopic retrograde cholangiopancreatography (ERCP) and placement of a nasobiliary drainage tube or a large bore indwelling plastic stent, as this is the preferred method of biliary decompression in most institutions 3, 4
• Alternatively, percutaneous transhepatic biliary drainage or surgical biliary decompression may be considered, but these carry a significantly higher morbidity and mortality 3

Antibiotic Therapy

The choice of antibiotic therapy should be guided by the risk factors for multi-drug resistant (MDR) pathogens, which include:

• Prior antibiotic exposure
• Prior biliary stenting
• Nosocomial acute cholangitis
• Male sex 5
• The use of broad-spectrum antibiotics, such as third-generation cephalosporins, and consideration of coverage for Enterococcus spp. and anaerobic infections 3, 6

Laboratory Studies and Imaging

The patient's laboratory studies and imaging results, including the leukocyte count, serum total bilirubin, serum aminotransferase, and abdominal ultrasonography, are consistent with acute cholangitis. Further studies, such as blood cultures and bile cultures, may be necessary to guide antibiotic therapy and management 6