From the Guidelines
Acute management of ascending cholangitis requires prompt intervention with antibiotics, fluid resuscitation, and biliary decompression, with the goal of reducing morbidity, mortality, and improving quality of life. The management of ascending cholangitis involves several key components, including:
- Hemodynamic stabilization through IV fluid resuscitation using crystalloids like normal saline or lactated Ringer's at 20-30 mL/kg
- Initiation of empiric broad-spectrum antibiotics immediately to cover gram-negative organisms and anaerobes; options include piperacillin-tazobactam 4.5g IV q6h, or a combination of ceftriaxone 2g IV daily plus metronidazole 500mg IV q8h, or ciprofloxacin 400mg IV q12h plus metronidazole, as recommended by the Tokyo Guidelines (TG13) 1
- Urgent biliary decompression, typically via endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours, or percutaneous transhepatic biliary drainage if ERCP is unavailable, as supported by the 2017 WSES guidelines for management of intra-abdominal infections 1
- Monitoring of vital signs, urine output, and laboratory values including liver function tests, white blood cell count, and blood cultures
- Patients with severe cholangitis presenting with hypotension, altered mental status, or organ dysfunction require ICU admission The pathophysiology of ascending cholangitis involves biliary obstruction (often from stones, strictures, or tumors) leading to bacterial proliferation and translocation into the bloodstream, causing systemic inflammatory response and potentially septic shock if untreated, highlighting the importance of early and aggressive management to reduce mortality rates, which can reach 10% even with appropriate treatment 1. The most recent and highest quality study, the 2017 WSES guidelines, recommends ERCP as the first-line treatment for biliary decompression in patients with moderate to severe acute cholangitis, with percutaneous transhepatic biliary drainage reserved for patients in whom ERCP fails 1.
From the Research
Acute Management of Ascending Cholangitis
The acute management of ascending cholangitis involves a combination of antibiotic therapy and biliary drainage. Key aspects of management include:
- Administration of broad-spectrum antibiotics to cover both gram-negative and gram-positive organisms associated with cholangitis 2
- Choice of antibiotics should be based on the severity of the disease and the presence of comorbid conditions 3, 4
- Biliary drainage is essential to relieve obstruction and prevent recurrence of cholangitis 2, 5, 6
- Endoscopic drainage is the preferred method for managing choledocholithiasis, with options ranging from endoscopic papillotomy and stone extraction to placement of a biliary drainage system 2
Antibiotic Therapy
Antibiotic therapy is a crucial component of the acute management of ascending cholangitis. Key considerations include:
- Initial therapy should cover Enterobacteriaceae, particularly Escherichia coli 6
- Activity against enterococci is not required, as their pathogenicity in biliary tract infections is unclear 6
- Coverage of anaerobes, such as Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, the elderly, and those in serious clinical condition 6
- Monotherapy with a ureidopenicillin, such as mezlocillin or piperacillin, is effective in patients with moderate clinical severity 6
- Combination therapy with an aminoglycoside may be preferable in severely ill patients with septicemia 6
Biliary Drainage
Biliary drainage is essential to relieve obstruction and prevent recurrence of cholangitis. Key considerations include:
- Endoscopic drainage is the preferred method for managing choledocholithiasis 2
- Transhepatic biliary drainage is reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones 2
- Surgical biliary decompression is seldom required in the emergency setting but plays an important role in the definitive treatment of the underlying cause 2