What is the treatment for asymptomatic ascending cholangitis post laparoscopic cholecystectomy with elevated Alkaline Phosphatase (ALK) and abnormal Liver Function Tests (LFT)?

From the Guidelines

For asymptomatic ascending cholangitis post laparoscopic cholecystectomy with elevated Alkaline Phosphatase (ALK) and abnormal Liver Function Tests (LFT), I strongly recommend a course of antibiotics targeting biliary pathogens, as the most recent and highest quality study suggests that antibiotic therapy is crucial in managing intra-abdominal infections, including cholangitis 1. The treatment should start with piperacillin-tazobactam 4.5g IV every 6 hours or ciprofloxacin 500mg orally twice daily plus metronidazole 500mg orally three times daily for 7-14 days, as these antibiotics have been shown to be effective in treating biliary infections 1.

Key Considerations

• The elevated alkaline phosphatase suggests ongoing biliary inflammation, and treating the infection can prevent progression to symptomatic disease or complications like liver abscess or sepsis.
• Monitor liver enzymes weekly during treatment to assess response, and consider repeat imaging to evaluate for occult biliary obstruction or stricture if no improvement occurs after 7 days.
• After completing antibiotics, follow up with repeat liver function tests in 2-4 weeks to ensure resolution, and consider consultation with a hepatobiliary specialist for further evaluation if enzymes remain elevated.

Treatment Approach

• The Italian Council for the Optimization of Antimicrobial Use recommends antibiotic therapy for 4-7 days in immunocompetent patients with adequate source control, and up to 7 days in immunocompromised or critically ill patients 1.
• The study by the Italian Council also suggests that patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant a diagnostic investigation 1.

Biliary Drainage

• Endoscopic sphincterotomy and stone extraction have been reported to be successful in more than 90% of cases, with adverse event rates close to 5% and mortality rates < 1% 1.
• Biliary drainage can be achieved through various methods, including ERC, percutaneous transhepatic cholangiography (PTC), EUS-guided drainage, or surgical drainage, and the choice of method depends on the disease severity and clinical context 1.

From the Research

Asymptomatic Ascending Cholangitis Post Laparoscopic Cholecystectomy

• The provided studies do not directly address the treatment for asymptomatic ascending cholangitis post laparoscopic cholecystectomy with elevated Alkaline Phosphatase (ALK) and abnormal Liver Function Tests (LFT) 2, 3, 4, 5, 6.
• However, some studies discuss the treatment of primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), which are cholestatic liver diseases that may present with similar laboratory abnormalities.
• Ursodeoxycholic acid (UDCA) is a commonly used treatment for PBC and PSC, and has been shown to improve liver chemistries and histology in some patients 3, 4, 5.
• In patients with PBC who do not respond to UDCA monotherapy, triple therapy with UDCA, prednisolone, and immunosuppressants may be effective 6.
• Elevated alkaline phosphatase (ALP) and total bilirubin (TBIL) levels, as well as a severe degree of fibrosis, have been identified as predictors of poor prognosis in patients with PBC 5, 6.
• Normalization of ALP and TBIL has been suggested as a new therapeutic target in PBC 5.

Treatment Options

• UDCA monotherapy or UDCA added to prednisolone and immunosuppressant triple therapy may be considered for patients with cholestatic liver diseases 3, 4, 5, 6.
• The choice of treatment should be individualized based on the patient's specific condition, laboratory results, and response to previous treatments 2, 5, 6.