What is the recommended management for cholangitis?

Management of Cholangitis

The management of cholangitis requires prompt administration of broad-spectrum antibiotics within 1 hour in cases of septic shock and biliary drainage based on severity, with urgent drainage within hours for severe cases (Grade III) and early drainage within 24 hours for moderate cases (Grade II). 1

Diagnosis

• Diagnosis based on clinical presentation, laboratory data, and imaging findings showing inflammation and biliary obstruction
• Common symptoms include fever, abdominal pain, and jaundice (Charcot's triad)
• Initial imaging with ultrasonography, followed by more sensitive modalities:
  • MRCP: Sensitivity 85%, specificity 93%
  • EUS: Sensitivity 93%, specificity 96% 1

Severity Classification

Cholangitis is classified into three grades according to the Tokyo Guidelines:

1. Grade I (Mild): Responds to initial medical treatment
2. Grade II (Moderate): Does not respond to initial treatment but no organ dysfunction
3. Grade III (Severe): Associated with organ dysfunction 1

Management Algorithm

1. Initial Management

• Fluid resuscitation to correct hypovolemia and electrolyte imbalances 2
• Correction of coagulopathy if present 2
• Early broad-spectrum antibiotics:
  • Start within 1 hour for septic shock
  • Start within 4 hours before drainage procedures 1
  • Continue for 3-5 days in uncomplicated cases with successful drainage
  • Continue for 7-10 days in complicated cases or persistent infection 1

2. Antibiotic Selection

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 1

Coverage should include enteric Gram-negative bacteria and enterococci, as biliary infections are often polymicrobial with common organisms including E. coli, Klebsiella, Enterococcus, Clostridium, Streptococcus, Pseudomonas, and Bacteroides species 3, 4

3. Biliary Drainage Based on Severity

• Grade III (Severe): Urgent drainage within hours
• Grade II (Moderate): Early drainage within 24 hours
• Grade I (Mild): Initial observation with antibiotics, drainage if no improvement 1

4. Drainage Method Selection

1. ERCP with sphincterotomy and stone extraction/stenting (first-line)

   • Success rate >90% for stone extraction 1
   • Preferred for choledocholithiasis 2

2. Percutaneous transhepatic biliary drainage (PTBD)

   • Alternative when ERCP fails
   • Preferred for suspected hilar cholangiocarcinoma or intrahepatic stones 2

3. EUS-guided drainage

   • Emerging alternative when ERCP is not feasible

4. Surgical drainage

   • Avoid in severe cholangitis due to high mortality rates
   • Particularly high risk in patients over 80 years old 1

Special Considerations

• Obtain bile cultures during biliary intervention to guide targeted antibiotic therapy 1
• Consider antifungal therapy in patients not responding to antibiotic therapy, as Candida species have been isolated in 12% of PSC patients undergoing ERCP 3
• For recurrent cholangitis (e.g., in PSC patients with complex intrahepatic cholangiopathy):
  • Avoid rotation of antibiotics which can lead to resistance
  • Seek expert multidisciplinary assessment including formal microbiology advice 3
  • Consider prophylactic antibiotics for patients undergoing ERCP 3

Pitfalls to Avoid

• Delaying antibiotics
• Delaying biliary decompression
• Overreliance on antibiotics alone without addressing the underlying obstruction
• Prolonged broad-spectrum antibiotics without culture guidance
• Using surgical drainage as first-line approach 1

Outcome Factors

• Prognosis depends on the nature of biliary obstruction (benign vs. malignant)
  • Better outcomes with benign conditions (83% vs. 59% cure rate) 5
• Mortality is higher when there is a delay in diagnosis and treatment, particularly in elderly patients with comorbidities 2

The key to successful management of cholangitis is the combination of appropriate antibiotic therapy and timely biliary decompression, with the specific approach tailored to the severity of the condition and the underlying cause of obstruction.