What is the treatment for Ascending Cholangitis?

From the Guidelines

Ascending cholangitis requires prompt treatment with antibiotics, biliary drainage, and supportive care, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary decompression. Initial management includes intravenous fluids for hemodynamic support and broad-spectrum antibiotics to cover enteric gram-negative bacteria, enterococci, and anaerobes, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1. Appropriate antibiotic regimens include piperacillin-tazobactam (3.375-4.5g IV every 6 hours), or a combination of a third-generation cephalosporin like ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), or a fluoroquinolone like ciprofloxacin (400mg IV every 12 hours) plus metronidazole, as suggested by the British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis 1.

Some key points to consider in the treatment of ascending cholangitis include:

• Biliary decompression is crucial and should be performed within 24-48 hours in moderate cases and urgently in severe cases, with ERCP being the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1.
• Percutaneous transhepatic cholangiography (PTC) or surgical decompression may be necessary in patients who cannot undergo ERCP, but these options are associated with higher morbidity and mortality rates 1.
• Supportive measures include pain management, correction of electrolyte abnormalities, and close monitoring of vital signs.
• The underlying pathophysiology involves biliary obstruction leading to bacterial colonization and subsequent infection, which explains why both antibiotics and drainage are essential components of treatment.

In terms of specific treatment options, the 2017 WSES guidelines recommend that ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, and that endoscopic nasobiliary drainage (ENBD) + endoscopic sphincterotomy (EST) are associated with lower morbidity and mortality rates compared to T-tube drainage under laparotomy 1. Additionally, the British Society of Gastroenterology and UK-PSC guidelines suggest that antifungal therapy should be considered in patients with cholangitis not responding to antibiotic therapy, and that rotation of antibiotics may be necessary in patients with recurrent cholangitis secondary to complex intrahepatic cholangiopathy 1.

Overall, the treatment of ascending cholangitis requires a multidisciplinary approach, with prompt initiation of antibiotics, biliary drainage, and supportive care, and careful consideration of the underlying pathophysiology and potential complications.

From the Research

Treatment Overview

The treatment for Ascending Cholangitis typically involves a combination of the following:

• Administration of intravenous fluids
• Antimicrobial therapy 2, 3
• Prompt drainage of the bile duct 2, 3

Antibiotic Therapy

• Antibiotics should be given for 7-10 days in therapeutic dosages 4
• Fever-based antibiotic therapy can be safe and effective when resolution of fever is achieved following endoscopic biliary drainage 5
• Broad spectrum penicillin can be an adequate therapy for acute cholangitis 6

Biliary Drainage

• Endoscopic biliary drainage is a common method used to drain the bile duct 5, 3
• Other available drainage options include percutaneous transhepatic cholangiography, endoscopic ultrasound, and open surgical drainage 3

Importance of Early Treatment

• Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes of the disease 2, 3
• Delayed treatment can lead to increased mortality and morbidity 3