Treatment of Acute Cholangitis
The treatment of acute cholangitis requires immediate empiric broad-spectrum antibiotics and biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP), with the timing and specific approach determined by disease severity. 1, 2
Initial Assessment and Management
- Severity assessment should be performed using established criteria such as the Tokyo Guidelines, which classify cholangitis as Grade III (severe), Grade II (moderate), or Grade I (mild) 1, 2
- Approximately 70% of patients respond to medical treatment comprising supportive care and antimicrobial therapy 1
- Patients with severe disease or significant comorbidities should be admitted to the intensive care unit 1, 2
Antibiotic Therapy
Initiate empiric broad-spectrum antibiotics immediately upon suspicion of cholangitis 1, 2
- For septic shock: administer within 1 hour
- For other cases: administer within 4 hours and before drainage procedures
Recommended antibiotic regimens include: 1, 2
- Beta-lactam/beta-lactamase inhibitor combinations (e.g., piperacillin/tazobactam for unstable patients)
- Cephalosporins (e.g., ceftriaxone plus metronidazole for stable patients)
- Carbapenems (e.g., ertapenem if risk factors for ESBLs)
- Fluoroquinolones plus metronidazole (only in stable patients with beta-lactam allergy)
Duration of antibiotic therapy: 1, 2
- Typically 3-5 days with successful biliary drainage
- Extended until resolution of anatomical alteration in cases of residual stones or ongoing obstruction
Biliary Decompression
The timing of biliary drainage should be based on severity of cholangitis: 1, 2
- Severe (Grade III): Urgent decompression
- Moderate (Grade II): Early decompression within 24 hours
- Mild (Grade I): Elective decompression after antibiotic response
ERCP is the first-line procedure for biliary decompression: 1, 2
- Endoscopic options include nasobiliary drain placement and endoscopic sphincterotomy with stone extraction
- Small sphincterotomy may be considered to prevent ascending cholangitis but is not routinely recommended 1
Alternative drainage approaches: 1, 2
- Percutaneous transhepatic biliary drainage (PTBD) when ERCP fails or is not feasible
- Surgical drainage only when endoscopic or percutaneous approaches are contraindicated or unsuccessful
Management Based on Patient Classification
- Class A or B patients with acute cholangitis: ERCP with short course antibiotic therapy 1
- Class C patients: ERCP with antibiotic therapy; duration determined by patient's condition, risk factors for resistant bacteria, and managed by multidisciplinary team 1
- For elderly patients or those from institutions (e.g., nursing homes), consider broader spectrum antibiotics due to potential colonization with multidrug-resistant organisms 1
Microbiological Considerations
Obtain bile samples for microbial testing at the beginning of drainage procedures 1, 2
Most common pathogens include: 1, 2
- Gram-negative bacteria: Escherichia coli, Klebsiella, Pseudomonas
- Anaerobes: Bacteroides species
- Gram-positive: Enterococci, Streptococci
Candida in bile is associated with poor prognosis and may indicate need for liver transplantation 1
Common Pitfalls to Avoid
- Delaying antibiotic administration in severe cases can increase mortality 2
- Failure to obtain adequate biliary drainage is associated with poor outcomes 2
- Continuing broad-spectrum antibiotics after they are no longer required can promote antibiotic resistance 1
- Overlooking fungal infection in patients not responding to antibiotic therapy 1, 2
- Underestimating need for ICU admission in patients with severe cholangitis 2
Special Considerations
- For recurrent cholangitis in patients with compromised biliary systems (e.g., endoprosthesis in situ), consider long-term prophylactic antibiotics 3
- In primary sclerosing cholangitis with dominant strictures, endoscopic dilatation with or without stenting should be considered 1, 2
- Cholecystostomy may be an option for critically ill patients with multiple comorbidities who are unfit for surgery 1