What is the treatment for acute cholangitis?

Treatment of Acute Cholangitis

The treatment of acute cholangitis requires prompt administration of broad-spectrum antibiotics and biliary decompression, preferably through endoscopic retrograde cholangiopancreatography (ERCP). 1

Initial Management

• Begin antibiotics empirically as early as possible in any patient with suspected cholangitis - within 1 hour if septic shock is present, otherwise within 4 hours 1
• Initial fluid resuscitation and correction of coagulopathy should be performed concurrently 2
• Patients with severe disease or significant comorbidities should be admitted to the intensive care unit 1

Antibiotic Therapy

First-line antibiotic options:

• For mild-moderate cases:
  • Aminopenicillin/beta-lactamase inhibitor combinations (can be administered orally) 1
  • Ceftriaxone plus metronidazole (in stable patients) 1
• For severe cases:
  • Piperacillin/tazobactam (sufficient anaerobic coverage) 1
  • Third-generation cephalosporins plus anaerobic coverage 1
  • Carbapenems (ertapenem, imipenem/cilastatin, meropenem) for unstable patients or if risk factors for ESBL-producing organisms 1

Duration of antibiotic therapy:

• 3-5 days is typically sufficient with successful biliary drainage 1, 3
• Can be discontinued when body temperature remains <37°C for 24 hours following successful drainage 3
• Longer courses may be needed with incomplete drainage or persistent obstruction 1

Biliary Decompression

Endoscopic drainage:

• ERCP is the treatment of choice for biliary decompression in moderate/severe acute cholangitis 1
• Options include:
  • Biliary stent placement 1
  • Nasobiliary drain placement 1
  • Endoscopic sphincterotomy with stone extraction (if choledocholithiasis is present) 1

Alternative drainage methods:

• Percutaneous transhepatic biliary drainage (PTBD) should be reserved for cases where ERCP fails or is contraindicated 1
• Open surgical drainage should only be used when endoscopic or percutaneous approaches are contraindicated or unsuccessful 1

Treatment Based on Severity Classification

Class A or B patients (stable):

• ERCP for biliary decompression with short-course antibiotic therapy 1
• Endoscopic sphincterotomy and stone extraction if choledocholithiasis is present 1

Class C patients (unstable/septic):

• Immediate ERCP for biliary decompression 1
• Broader-spectrum antibiotics (piperacillin/tazobactam, carbapenems) 1
• Duration of antibiotics should be determined based on clinical response, risk factors for resistant bacteria, and through multidisciplinary consultation 1

Special Considerations

• Obtain bile samples for microbial testing during drainage procedures to guide targeted antibiotic therapy 1
• Most common pathogens include gram-negative enteric bacteria (E. coli, Klebsiella, Pseudomonas), anaerobes (Bacteroides), and gram-positive organisms (Enterococci, Streptococci) 1
• Antibiotic selection should consider local resistance patterns and be adjusted based on culture results 1
• Patients with biliary stents or previous biliary surgery are at higher risk for resistant organisms and may require broader empiric coverage 1
• Candida in bile is associated with poor prognosis and may indicate advanced disease 1