From the Guidelines
Cholangitis should be treated with immediate antibiotics, fluid resuscitation, and biliary decompression, with a focus on early recognition and treatment to reduce mortality rates, as recommended by the most recent guidelines 1. The diagnosis of cholangitis typically involves the presentation of Charcot's triad: right upper quadrant pain, fever, and jaundice, with Reynolds' pentad indicating severe, life-threatening cholangitis requiring immediate intervention.
Causes and Presentation
The most common cause of cholangitis is choledocholithiasis, which is the obstruction of the bile duct by gallstones, as stated in the 2017 WSES guidelines for management of intra-abdominal infections 1. Other causes include strictures or tumors.
Treatment
For empiric antibiotic therapy, options such as piperacillin-tazobactam 3.375g IV every 6 hours, or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours are recommended, with meropenem 1g IV every 8 hours used in severe cases, as supported by the Tokyo guidelines (TG13) for acute cholangitis 1.
Biliary Decompression
Biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis, as demonstrated by a randomized controlled trial (RCT) comparing endoscopic and open drainage in patients with severe acute cholangitis 1.
Key Considerations
Key elements of therapy include adequate antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction, with the type and timing of biliary drainage based on the severity of the clinical presentation and the availability and feasibility of drainage techniques, as outlined in the 2017 WSES guidelines 1.
Recommendations
The most effective approach for managing cholangitis involves a combination of antibiotics and biliary decompression, with ERCP as the preferred method for biliary decompression, and percutaneous transhepatic cholangiography (PTC) or open surgical drainage reserved for cases where ERCP is not feasible or has failed, as recommended by the 2017 WSES guidelines 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
- Diagnostic studies, such as blood and bile cultures, are necessary to confirm the diagnosis and identify the underlying cause of the infection 2
Treatment of Cholangitis
- Early broad-spectrum antibiotics, fluid resuscitation, and biliary decompression are essential for the treatment of cholangitis 2
- Ciprofloxacin has been shown to be an effective empirical therapy for patients with cholangitis, with a response rate of 85% 3
- Fever-based antibiotic therapy, where antibiotics are discontinued after the resolution of clinical symptoms, has been shown to be safe and effective in patients with acute cholangitis following successful endoscopic biliary drainage 4
- The choice of antibiotics should reflect local resistance patterns and avoid the overuse of broad-spectrum agents, with carbapenems being necessary to achieve a high antibiotic coverage in some cases 5
- Ciprofloxacin has also been shown to be effective in the treatment of severe biliary tract infections, including cholangitis, with a complete clinical and bacteriological cure rate of 87.5% 6
Antibiotic Therapy
- The most common pathogens isolated in cholangitis are Escherichia coli, Klebsiella spp., and Enterococcus spp. 3
- Antibiotic resistance rates are high, with enterobacterales showing resistance rates of >20% for fluorochinolones, cephalosporines, and acylureidopenicillins 5
- Carbapenems have been shown to have a low resistance rate (<2%) and may be necessary to achieve a high antibiotic coverage in some cases 5
- Piperacillin/tazobactam may be an effective carbapenem-sparing regimen for patients with community-acquired cholangitis without biliary prosthesis who do not need intensive care 5