What is the treatment for acute cholangitis?

Treatment of Acute Cholangitis

The treatment of acute cholangitis requires early administration of broad-spectrum antibiotics and biliary drainage, with timing of drainage based on severity according to the Tokyo Criteria. 1

Diagnosis and Classification

Acute cholangitis is diagnosed using the Tokyo Criteria, which considers:

• Clinical features: Fever/chills, abdominal pain (right upper quadrant/epigastrium), and jaundice (Charcot's triad)
• Laboratory data: Elevated inflammatory markers and liver function tests
• Imaging findings: Biliary dilatation or evidence of obstruction

Severity classification (Tokyo Criteria) 1:

• Grade I (Mild): No organ dysfunction
• Grade II (Moderate): Presence of any two conditions: WBC >12,000/mm³ or <4,000/mm³, high fever (≥39°C), age ≥75 years, hyperbilirubinemia, or hypoalbuminemia
• Grade III (Severe): Organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, or hematological)

Treatment Algorithm

1. Initial Management

• Fluid resuscitation and hemodynamic support
• Antibiotic therapy: Start immediately upon clinical suspicion 1
  • Within 1 hour for septic shock
  • Within 4 hours before drainage procedures
  • First-line options:
    • Piperacillin/tazobactam
    • Third/fourth-generation cephalosporins
    • Amoxicillin/clavulanate
  • For penicillin allergy: Ciprofloxacin or levofloxacin + metronidazole
  • For severe sepsis or risk of resistant organisms: Carbapenems

2. Biliary Drainage

Timing based on severity 1:

• Grade III (Severe): Urgent decompression within hours
• Grade II (Moderate): Early decompression (<24 hours after admission)
• Grade I (Mild): Initial observation with antibiotics; drainage if no improvement

Drainage methods (in order of preference) 1:

1. ERCP with sphincterotomy and stone extraction/stenting (success rate >90%)
2. Percutaneous transhepatic biliary drainage (PTBD)
3. EUS-guided biliary drainage
4. Surgical drainage (avoid in severe cases due to high mortality)

3. Duration of Therapy

• Antibiotics: 1, 2
  • Uncomplicated cases with successful drainage: 3-5 days
  • Complicated cases or persistent infection: 7-10 days
  • Adjust based on culture results (obtain bile cultures during biliary intervention)

Special Considerations

• Antibiotic selection: Consider local resistance patterns and patient risk factors 1
• Surgical drainage: Should be avoided in severe cholangitis, especially in patients >80 years old 1
• Multidisciplinary approach: Involve gastroenterology, interventional radiology, and infectious disease specialists for severe cases 1

Common Pitfalls to Avoid

• Delaying antibiotics: Can lead to increased mortality
• Delaying biliary decompression: Critical for severe cases
• Overreliance on antibiotics alone: Drainage is essential
• Prolonged broad-spectrum antibiotics: Unnecessary beyond 4 days for severe cases with successful drainage 1
• Choosing surgical drainage as first-line: Associated with higher morbidity and mortality compared to endoscopic approaches 1

Diagnostic Imaging

• Ultrasonography: First-line evaluation (limited sensitivity 25-63% for CBD stones) 1
• MRCP: High diagnostic accuracy (sensitivity 85%, specificity 93%) 1
• EUS: Minimally invasive with excellent accuracy (sensitivity 93%, specificity 96%) 1

While older studies suggested longer antibiotic courses of 7-10 days 2, more recent guidelines recommend shorter courses of 3-5 days for uncomplicated cases with successful drainage 1. Additionally, routine addition of metronidazole to third-generation cephalosporins has not been shown to improve outcomes when timely biliary drainage is performed 3.