From the Guidelines
Cholangitis is an infection of the bile ducts, typically caused by bacterial growth in obstructed bile ducts, and immediate treatment involves antibiotics, fluid resuscitation, and biliary decompression, with the goal of reducing morbidity, mortality, and improving quality of life. The diagnosis of cholangitis is based on clinical presentation, laboratory results, and imaging studies. Patients typically present with Charcot's triad (fever, right upper quadrant pain, and jaundice), though only about 50-70% of patients exhibit all three symptoms 1.
Treatment
For empiric antibiotic therapy, piperacillin-tazobactam 3.375g IV every 6 hours, or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours are recommended options 1. In severe cases, meropenem 1g IV every 8 hours may be used.
Duration of Antibiotic Therapy
Antibiotics should be continued for 4-7 days total, depending on clinical response, with the duration of therapy based on the severity of the clinical presentation and the adequacy of source control 1.
Biliary Decompression
Urgent biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP) should be performed within 24-48 hours for moderate cases and within 12 hours for severe cases 1. Some key points to consider in the management of cholangitis include:
- Common causes of obstruction include gallstones, strictures, or malignancy, which must be addressed to prevent recurrence 1.
- Patients with severe acute cholangitis and dominant bile duct strictures require urgent biliary decompression, as the mortality in those untreated is high 1.
- The type and timing of biliary drainage should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques, such as ERCP, percutaneous transhepatic cholangiography (PTC), and open surgical drainage 1. If left untreated, cholangitis can progress to septic shock and has a mortality rate of 10-30%, making prompt diagnosis and treatment essential 1.
From the Research
Diagnosis of Cholangitis
- Cholangitis is a life-threatening infection of the biliary tract that requires early recognition and treatment 2
- The diagnosis of cholangitis can be challenging, as many patients do not present with the classic symptoms of Charcot's triad 2
- Imaging evaluation of the hepatobiliary system, including endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography, is crucial in the management of cholangitis 3
Treatment of Cholangitis
- Early broad-spectrum antibiotics, fluid resuscitation, and biliary decompression are essential in the treatment of cholangitis 2, 4
- Endoscopic drainage is preferred over percutaneous drainage, and biliary decompression should be performed within 48 hours 4
- Sphincterotomy and stone removal should be combined with drainage, unless the patient is too unstable to tolerate more extensive endoscopic treatment 4
- Antibiotic treatment is effective in managing acute cholangitis, while immunosuppressive drugs may be used in the treatment of IgG4-associated cholangitis 3
- Surgical interventions are generally restricted to patients in whom other therapeutic approaches have failed 3
Role of Antibiotics in Cholangitis
- Broad-spectrum antibiotics are essential in the treatment of cholangitis, with the most common pathogens being E. coli and Streptococcus viridans 2, 5
- Ciprofloxacin may be used in the treatment of cholangitis, but its role in reducing cholangitis in patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatography is unclear 5
Biliary Drainage Procedures
- Endoscopic nasobiliary drainage is a safe and effective method for treating patients with acute cholangitis and preventing its development after endoscopic retrograde cholangiography 6
- Biliary drainage procedures, including endoscopic retrograde cholangiography and percutaneous transhepatic drainage, are necessary for controlling the progression of cholangitis 3, 6