What are the latest guidelines for managing acute cholangitis?

Management of Acute Cholangitis: Latest Guidelines

Acute cholangitis requires prompt antibiotic therapy and biliary decompression, with ERCP being the first-line drainage procedure for moderate to severe cases. 1

Diagnosis and Classification

• Diagnosis based on the Tokyo Guidelines criteria:

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

• Diagnostic criteria include:

  • Clinical: Fever, jaundice, abdominal pain (Charcot's triad)
  • Laboratory: Elevated inflammatory markers, liver function tests
  • Imaging: Biliary dilation (>8mm in patients <50 years old) 1

• First-line imaging:

  • Ultrasonography (sensitivity 25-63% for CBD stones)
  • MRCP (sensitivity 85%, specificity 93%)
  • EUS (sensitivity 93%, specificity 96%) 1

Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately upon clinical suspicion 1

• Recommended regimens based on severity:

  1. Community-acquired cholangitis (stable patients): 2

     • Beta-lactam/beta-lactamase inhibitors: Amoxicillin/clavulanate or ticarcillin/clavulanate
     • Cephalosporins: Ceftriaxone + metronidazole
     • Alternative (beta-lactam allergy): Ciprofloxacin/levofloxacin + metronidazole

  2. Unstable patients or healthcare-associated infections: 2

     • Piperacillin/tazobactam
     • Cefepime + metronidazole
     • Carbapenems (ertapenem, imipenem, meropenem)
     • Tigecycline (if risk for ESBL-producing organisms)

• Duration of therapy: 1

  • 3-5 days for uncomplicated cases with successful drainage
  • 7-10 days for complicated cases or persistent infection

• Obtain bile cultures during biliary intervention to guide targeted antibiotic therapy 1

Biliary Decompression

• Timing of decompression: 2, 1

  • Grade III (Severe): Urgent drainage within hours
  • Grade II (Moderate): Early drainage within 24 hours
  • Grade I (Mild): Elective drainage if medical therapy fails

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

  1. ERCP with sphincterotomy and stone extraction/stenting (success rate >90%)
  2. Percutaneous transhepatic biliary drainage (PTBD) when ERCP fails
  3. EUS-guided biliary drainage as an emerging alternative
  4. Open surgical drainage as last resort (avoid in severe cases due to high mortality)

Management Algorithm

1. Initial Assessment:

   • Evaluate severity using Tokyo Guidelines criteria
   • Obtain blood cultures, liver function tests, inflammatory markers
   • Perform initial imaging (ultrasonography)

2. Initial Management:

   • Fluid resuscitation
   • Broad-spectrum antibiotics within 1 hour for severe sepsis 2
   • Pain management

3. Biliary Decompression:

   • Grade III: Urgent ERCP/PTBD within hours
   • Grade II: Early ERCP/PTBD within 24 hours
   • Grade I: Elective drainage if medical therapy fails

4. Definitive Treatment:

   • Address underlying cause (stone extraction, stent placement for strictures)
   • Cholecystectomy for gallstone-related cholangitis after resolution of acute episode

Special Considerations

• Recurrent cholangitis: 1

  • Consider multidisciplinary assessment
  • Formal microbiology advice for antibiotic selection
  • Consider prophylactic antibiotics for patients undergoing ERCP

• Elderly patients: 2

  • Age alone is not a contraindication for intervention
  • Consider comorbidities and frailty in decision-making
  • Higher risk of mortality with delayed treatment

• Common pitfalls to avoid: 1

  • Delaying antibiotics
  • Delaying biliary decompression
  • Overreliance on antibiotics alone without drainage
  • Prolonged broad-spectrum antibiotics without culture guidance
  • Surgical drainage as first-line (associated with higher morbidity)

By following these guidelines, clinicians can optimize outcomes for patients with acute cholangitis through prompt diagnosis, appropriate antibiotic therapy, and timely biliary decompression.