How should ascending cholangitis be treated?

Treatment of Ascending Cholangitis

Ascending cholangitis should be treated with prompt antibiotic therapy and biliary decompression, with the timing of decompression based on severity of presentation. 1, 2

Initial Assessment and Classification

Acute cholangitis is classified into three severity grades:

• Grade III (severe): Presence of organ dysfunction
• Grade II (moderate): Risk of increasing severity without early biliary drainage
• Grade I (mild): Less severe cases 2

Treatment Algorithm

1. Immediate Interventions

• Intravenous fluid resuscitation to correct hypovolemia and electrolyte imbalances
• Empiric antibiotic therapy should be started immediately after blood cultures are obtained
  • First-line: Amoxicillin/Clavulanate 2g/0.2g q8h IV for immunocompetent patients 2
  • Alternative regimens:
    • Third-generation cephalosporins (without routine addition of metronidazole) 3
    • Ciprofloxacin for patients with penicillin allergy 3

2. Biliary Decompression

• Timing of decompression depends on severity:

  • Severe cholangitis (Grade III): Urgent biliary decompression within 24 hours 2
  • Moderate cholangitis (Grade II): Early biliary decompression (within 48-72 hours)
  • Mild cholangitis (Grade I): Elective decompression after clinical improvement with antibiotics

• Decompression methods (in order of preference):

  1. ERCP with endoscopic dilation ± stent placement (first-line) 2
  2. Percutaneous transhepatic biliary drainage (PTBD) if ERCP fails 2
  3. Surgical open drainage only as last resort when other methods fail or are contraindicated 2

3. Duration of Antibiotic Therapy

• Immunocompetent patients with adequate source control: 4 days
• Immunocompromised or critically ill patients: Up to 7 days 2

Management of Specific Scenarios

Recurrent Cholangitis

• Evaluate for underlying strictures or incomplete biliary drainage 2
• Consider long-term maintenance antibiotic therapy for recurrent episodes 2
• For patients with bacterial cholangitis refractory to treatment, evaluate for liver transplantation 2

Cholangitis with Biliary Stents/Drains

• Immediate flushing of biliary drains in febrile patients using sterile technique and normal saline (10-20 mL) 2
• Obtain bile samples for culture and sensitivity testing 2
• Monitor for resistant organisms with prolonged/recurrent antibiotic use 2

Cholangitis in PSC (Primary Sclerosing Cholangitis)

• Acute bacterial cholangitis should be treated with antibiotics and subsequent biliary decompression if an underlying relevant stricture is present 1
• For patients with PSC and recurrent bacterial cholangitis not controlled by antibiotics, consider liver transplantation 1

Common Pitfalls and Caveats

1. Delayed biliary decompression in severe cases can lead to increased mortality
2. Inadequate antibiotic coverage - consider local resistance patterns when selecting empiric therapy
3. Incomplete biliary drainage is a risk factor for recurrent cholangitis 2
4. Prolonged antibiotic use increases risk of developing resistant organisms 2
5. Routine addition of metronidazole to third-generation cephalosporins has not been shown to improve outcomes when efficient biliary drainage is performed 3

Early diagnosis and prompt treatment are crucial to prevent the potentially fatal progression of ascending cholangitis, with mortality rates historically reported between 11-27% in severe cases 4.