What is the treatment for acute cholangitis?

Treatment of Acute Cholangitis

The treatment of acute cholangitis requires prompt biliary decompression via ERCP and immediate broad-spectrum antibiotic therapy, with timing of intervention based on severity grade. 1, 2

Diagnosis and Classification

Acute cholangitis is characterized by inflammation and infection of the bile ducts resulting from biliary obstruction (commonly choledocholithiasis) combined with bacterial growth in bile. Diagnosis is based on:

• Clinical features: Fever/chills, right upper quadrant pain, and jaundice (Charcot's triad)
• Laboratory findings: Elevated inflammatory markers, liver enzymes
• Imaging: Ultrasonography, MRCP, or EUS showing biliary dilation

The Tokyo Guidelines classify cholangitis into three severity grades:

• Grade I (Mild): Responds to medical therapy
• Grade II (Moderate): Requires early biliary drainage
• Grade III (Severe): Organ dysfunction requiring urgent drainage and intensive care

Treatment Algorithm

1. Immediate Management

• Antibiotics: Start immediately upon clinical suspicion 2

  • For septic shock: Within 1 hour
  • For other cases: Within 4 hours before drainage
  • Cover enteric gram-negative bacteria and enterococci

• Recommended empiric regimens 1:

  • First-line options:
    • Piperacillin/tazobactam (preferred for unstable patients)
    • Third/fourth-generation cephalosporins (ceftriaxone, cefepime) + metronidazole
    • Amoxicillin/clavulanate or ticarcillin/clavulanate (for stable patients)
  • For penicillin allergy:
    • Ciprofloxacin or levofloxacin + metronidazole
  • For severe sepsis or risk of resistant organisms:
    • Carbapenems (imipenem, meropenem, ertapenem)

2. Biliary Decompression

• Grade III (Severe): Urgent decompression (within hours) 1, 2

• Grade II (Moderate): Early decompression (<24 hours after admission) 2

• Grade I (Mild): Initial observation with antibiotics, drainage if no improvement

• Drainage methods (in order of preference) 1, 2:

  1. ERCP with sphincterotomy and stone extraction/stenting: First-line (success rate >90%)
  2. Percutaneous transhepatic biliary drainage (PTBD): When ERCP fails
  3. EUS-guided drainage: Emerging alternative after failed ERCP
  4. Open surgical drainage: Last resort when other methods fail or are contraindicated

3. Antibiotic Duration

• Uncomplicated cases with successful drainage: 3-5 days 1
• Complicated cases or persistent infection: 7-10 days 3
• Adjust based on culture results: Tailor therapy once bile cultures are available

Special Considerations

• Bile cultures: Should be obtained during biliary intervention to guide targeted antibiotic therapy 4
• Resistant organisms: Consider local resistance patterns and patient risk factors (prior hospitalization, previous antibiotics) 2
• Recurrent cholangitis: May require scheduled stent exchanges or consideration of maintenance antibiotic therapy in selected cases 3
• Multidisciplinary approach: Involve gastroenterology, interventional radiology, and infectious disease specialists, especially for severe cases 1

Pitfalls to Avoid

• Delaying antibiotics: Mortality increases with delayed antimicrobial therapy in septic patients
• Delaying biliary decompression: Early drainage significantly reduces mortality in moderate/severe cases 2
• Overreliance on antibiotics alone: Source control through biliary drainage is essential for successful treatment 1
• Prolonged broad-spectrum antibiotics: De-escalate based on culture results to prevent resistance 1
• Surgical drainage as first-line: Associated with higher morbidity and mortality compared to endoscopic approaches 1

The combination of appropriate antibiotics and timely biliary decompression is crucial for successful management of acute cholangitis, with the timing and aggressiveness of intervention guided by severity classification.