What is the management of ascending cholangitis?

Management of Ascending Cholangitis

The management of ascending cholangitis requires immediate fluid resuscitation, broad-spectrum antibiotics, and prompt biliary decompression, with ERCP being the first-line intervention for biliary drainage. 1, 2

Initial Assessment and Stabilization

• Diagnosis: Based on clinical presentation (fever, jaundice, abdominal pain), laboratory tests (elevated liver function tests, inflammatory markers), and imaging (ultrasound, MRCP, or CT scan) 1
• Severity classification:
  • Grade I (mild): Responds to medical therapy
  • Grade II (moderate): Requires early biliary drainage
  • Grade III (severe): Presents with organ dysfunction requiring urgent intervention 1

Medical Management

Antibiotic Therapy

• First-line antibiotic: Amoxicillin/Clavulanate 2g/0.2g q8h IV for immunocompetent patients 1
• Duration of therapy:
  • 4 days for immunocompetent patients with adequate source control
  • Up to 7 days for immunocompromised or critically ill patients 1
  • Extended to 2 weeks if Enterococcus or Streptococcus is isolated 1

Supportive Care

• Aggressive fluid resuscitation to correct hypovolemia and electrolyte imbalances 2
• Correction of coagulopathy if present 2
• Close monitoring of vital signs and organ function 3

Biliary Decompression

Timing of Intervention

• Urgent decompression: For patients with septic shock or those not responding to antibiotics within 12-24 hours 1, 2
• Early decompression: Within 48-72 hours for patients who initially respond to antibiotics 1, 3

Methods of Biliary Drainage

1. Endoscopic Retrograde Cholangiopancreatography (ERCP):

   • First-line intervention for biliary drainage 1
   • Biliary dilatation is preferred over stent insertion for dominant strictures 4
   • Pathological sampling of suspicious strictures is mandatory 4
   • Prophylactic antibiotics should be administered before the procedure 4

2. Percutaneous Transhepatic Biliary Drainage (PTBD):

   • Second-line option when ERCP fails or is not feasible 1
   • Useful alternative for hilar obstruction or intrahepatic stones 2

3. Surgical Drainage:

   • Reserved as a last resort when endoscopic or percutaneous methods fail or are contraindicated 1, 2
   • Rarely required in emergency settings 2

Management of Underlying Causes

Choledocholithiasis

• Endoscopic papillotomy with stone extraction for stable patients 2
• Temporary stent placement with or without papillotomy for unstable patients with ongoing sepsis 2
• Consider cholecystectomy after bile duct clearance to prevent recurrence 1

Malignant Biliary Obstruction

• Multidisciplinary team assessment is essential 4
• Stent placement (plastic or metal) based on expected survival 1
• Further oncological management as appropriate 1

Post-Procedural Care

• Adequate biliary drainage must be maintained to prevent recurrence 1
• For patients with biliary drains:
  • Regular flushing with sterile technique using 10-20 mL normal saline
  • Immediate flushing for febrile patients
  • Observation of return fluid and obtaining samples for culture when indicated 1

Prevention of Recurrence

• Definitive treatment of underlying cause (stone removal, stent exchange, etc.) 1, 2
• For patients with recurrent cholangitis:
  • Consider long-term maintenance antibiotic therapy 5
  • Evaluate for liver transplantation in refractory cases 1

Common Pitfalls and Caveats

1. Delayed recognition and intervention: Failure to promptly diagnose and treat cholangitis can lead to increased mortality, particularly in elderly patients with comorbidities 2

2. Inadequate source control: Incomplete biliary drainage is a major risk factor for persistent or recurrent infection 1

3. Overreliance on antibiotics alone: While antibiotics are essential, they cannot substitute for adequate biliary decompression in obstructive cholangitis 2, 3

4. Inappropriate antibiotic duration: Prolonged antibiotic use increases the risk of developing resistant organisms 1

5. Failure to investigate underlying cause: All patients should undergo appropriate imaging and evaluation to determine and address the root cause of biliary obstruction 1, 3