Is percutaneous drainage a viable option for managing acute cholangitis?

Percutaneous Drainage in Acute Cholangitis Management

Percutaneous biliary drainage (PTBD) is a viable second-line option for managing acute cholangitis, but should be reserved for patients in whom endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible due to anatomical limitations or unsuccessful biliary cannulation.1

Drainage Approach Hierarchy

• ERCP is the first-line and treatment of choice for biliary decompression in patients with moderate to severe acute cholangitis (Recommendation 1A) 1
• Percutaneous transhepatic biliary drainage (PTBD) should be used as a second-line approach when ERCP fails or cannot be performed (Recommendation 1B) 1
• Open surgical drainage should only be considered when both endoscopic and percutaneous approaches are contraindicated or have failed (Recommendation 2C) 1

Indications for Percutaneous Drainage

• Unsuccessful biliary cannulation during ERCP 1
• Anatomically inaccessible papilla (e.g., surgically altered anatomy) 1
• Failed ERCP despite multiple attempts 1
• When emergent decompression is needed and ERCP expertise is unavailable 1

Timing of Drainage

• Timing of biliary decompression is dictated by the severity of acute cholangitis according to Tokyo Guidelines grading system 1:
  • Severe (grade 3) cholangitis: urgent decompression required 1
  • Moderate (grade 2) cholangitis: early decompression (within 24 hours) significantly reduces 30-day mortality 1
  • Mild (grade 1) cholangitis: can be initially observed on medical treatment 1

Technique and Considerations for PTBD

• Percutaneous transhepatic cholangiography (PTC) is performed first to identify the biliary anatomy 2
• Following successful PTC, a drainage catheter is placed to decompress the biliary system 3
• Balloon dilation of strictures can be initiated at the time of initial access, though waiting 2-4 weeks after initial access is generally advisable 1
• Large caliber catheters should be used to maintain duct patency and determine minimum diameter for scarring after dilatation 1

Complications of PTBD

• PTBD carries significant risks including 1:
  • Biliary peritonitis 1
  • Hemobilia 1
  • Pneumothorax 1
  • Hematoma 1
  • Liver abscesses 1
  • Patient discomfort related to external catheter 1

Efficacy and Outcomes

• A 1997 study of 143 patients showed that biliary drainage (including percutaneous methods when endoscopic approaches failed) was effective in resolving cholangitis in 96.7% of cases 4
• A 2012 retrospective study confirmed the clinical efficacy of percutaneous drainage as a viable alternative when endoscopic approaches fail 1
• Percutaneous approaches have been shown to facilitate subsequent endoscopic or surgical intervention 1

Duration of Drainage

• There is no consensus on the optimal duration of catheter indwell time after dilatation 1
• Studies have shown improved patency with stenting for >6 months compared with <4 months without stenting 1

Practical Considerations

• Antibiotics and fluid resuscitation should be initiated promptly before any drainage procedure 1
• For patients with sepsis, appropriate antibiotics should be initiated within 1 hour of diagnosis 1
• In less severe cases, antibiotics should be administered within 6 hours of diagnosis 1
• The focus in severe biliary sepsis should be on biliary decompression with the least manipulation of the biliary tree possible 1

While percutaneous drainage is a viable option for managing acute cholangitis, it should be considered only after ERCP has failed or is not feasible, given its higher complication rates and lower success rates compared to endoscopic approaches.