What is the treatment for acute cholangitis?

Treatment of Acute Cholangitis

The treatment of acute cholangitis requires prompt biliary decompression combined with early antibiotic therapy, with timing based on severity of presentation. 1

Initial Assessment and Management

Severity Classification

• Grade III (Severe): Presence of organ dysfunction
• Grade II (Moderate): Risk of increased severity without early biliary drainage
• Grade I (Mild): Responds to medical therapy alone 1

Immediate Management

1. Fluid resuscitation and correction of coagulopathy
2. Antibiotic therapy:
   • For septic shock: Start antibiotics within 1 hour
   • For non-shock cases: Start antibiotics within 4 hours of presentation 1
   • Obtain blood cultures before starting antibiotics (though their clinical utility is debated) 1

Antibiotic Therapy

Empiric Antibiotic Selection

• First-line options (based on severity):
  • Mild/Moderate cases:
    • Aminopenicillin/beta-lactamase inhibitor (e.g., amoxicillin/clavulanate) 1
    • Ceftriaxone + metronidazole 1
  • Severe cases/unstable patients:
    • Piperacillin/tazobactam 1
    • Carbapenems (imipenem/cilastatin, meropenem, ertapenem) 1
    • Cefepime + metronidazole 1

Special Considerations

• For penicillin allergy: Fluoroquinolones (ciprofloxacin) + metronidazole 1
• For patients with risk factors for ESBL-producing organisms: Carbapenems or tigecycline 1
• For shock: Consider adding amikacin 1
• For fragile patients or delayed diagnosis: Consider adding fluconazole 1

Duration of Therapy

• After successful biliary drainage:
  • 3-5 days if adequate source control is achieved 1
  • Continue until resolution of fever (temperature <37°C for 24 hours) 2
• With residual stones or ongoing biliary obstruction:
  • Continue antibiotics until resolution of the anatomical alteration 1

Biliary Decompression

Timing of Intervention

• Grade III (Severe): Urgent biliary decompression required 1
• Grade II (Moderate): Early biliary decompression (within 24-48 hours) 1
• Grade I (Mild): May respond to antibiotics alone; decompression can be scheduled electively 1

Methods of Biliary Decompression

1. Endoscopic Retrograde Cholangiopancreatography (ERCP) - first-line approach:

   • Options include:
     • Endoscopic sphincterotomy with stone extraction
     • Biliary stent placement
     • Nasobiliary drainage 1
   • Success rate >90% with complication rates around 5% 1

2. Percutaneous Transhepatic Cholangiography (PTC):

   • Reserved for cases where ERCP fails or is contraindicated
   • Useful for hilar cholangiocarcinoma or intrahepatic stones 3

3. EUS-guided biliary drainage:

   • Alternative after failed ERCP access 1

4. Surgical drainage:

   • Rarely required in emergency settings
   • May be needed for definitive treatment of underlying cause 3

Special Considerations

Microbiology

• Most common organisms:
  • Gram-negative: E. coli, Klebsiella, Pseudomonas
  • Gram-positive: Enterococci, Streptococci
  • Anaerobes: Bacteroides species 1
• Obtain bile cultures during drainage procedures 1
• Tailor antibiotics based on culture results and local resistance patterns

Common Pitfalls

1. Delayed recognition and treatment: Mortality increases with delayed intervention, especially in elderly patients with comorbidities 3
2. Inadequate source control: Antibiotics alone are insufficient without addressing biliary obstruction 1
3. Prolonged antibiotic use: Unnecessary continuation of broad-spectrum antibiotics after successful drainage increases resistance risk 1
4. Failure to recognize fungal infection: Consider antifungal therapy in patients not responding to antibiotics 1
5. Inadequate follow-up: Underlying cause (stones, malignancy) must be addressed to prevent recurrence 3

Outcomes

• Prognosis is significantly better for benign causes (83% cure rate) versus malignant obstruction (59% cure rate) 4
• Mortality has decreased from nearly 100% to 2.7-10% with modern management approaches 1
• Routine addition of metronidazole to third-generation cephalosporins may not improve outcomes when prompt biliary drainage is performed 5