What is the management plan for cholangitis?

Management Plan for Cholangitis - Full SOAP

SUBJECTIVE

Key Clinical Features to Assess:

• Classic Charcot's Triad (present in minority of cases): fever, jaundice, right upper quadrant pain 1
• Reynolds Pentad (severe disease): Charcot's triad plus altered mental status and hypotension 1
• Alarm symptoms: fever, abdominal pain, distention, jaundice, nausea, vomiting 2
• Risk factors: recent biliary instrumentation, choledocholithiasis, biliary strictures, malignancy, prior biliary surgery 3
• Comorbidities: assess for immunosuppression, cirrhosis, portal hypertension, underlying malignancy 4

OBJECTIVE

Laboratory Assessment:

• Liver function tests: direct and indirect bilirubin, AST, ALT, ALP, GGT, albumin 2
• Inflammatory markers: CRP, procalcitonin, lactate (for severity assessment and monitoring) 2
• Blood cultures: obtain before antibiotics in stable patients; do not delay antibiotics >1 hour in severe sepsis/shock 2
• Bile cultures: obtain at time of drainage procedure 5

Imaging Studies:

• First-line: Abdominal triphasic CT to detect intra-abdominal fluid collections and ductal dilation 2
• Complementary: MRCP for exact visualization, localization, and classification of biliary obstruction 2, 5
• Dynamic liver MRI or contrast CT: for new/changing symptoms or evolving laboratory abnormalities 2

Severity Grading:

Apply Tokyo Guidelines criteria to classify as Grade I (mild), Grade II (moderate), or Grade III (severe) to guide timing of intervention 5

ASSESSMENT

Diagnosis Confirmation:

Acute cholangitis with severity classification based on clinical presentation, laboratory findings, and imaging demonstrating biliary obstruction with infection 5

Differential Considerations:

Rule out cholecystitis, hepatic abscess, malignant obstruction, primary sclerosing cholangitis with dominant stricture 2

PLAN

1. Immediate Resuscitation and Antibiotic Therapy

Antibiotic Administration (Critical Priority):

• Timing: Within 1 hour for septic shock; within 4 hours for all other cases 5
• In patients without shock: May obtain radiological/bacteriological sampling with up to 6-hour delay before antibiotics 2
• In severe sepsis/shock: Substantially shorten investigation window, start broad-spectrum antibiotics within 1 hour 2

Antibiotic Regimen:

Broad-spectrum options (choose one) 2, 5:

• Piperacillin/tazobactam
• 4th-generation cephalosporin
• Imipenem/cilastatin
• Meropenem
• Ertapenem
• Aztreonam

Additional coverage:

• Add amikacin in cases of associated shock 2
• Add fluconazole in fragile patients or delayed diagnosis 2, 5
• Tailor antibiotics to bile and blood culture results once available 2

Antibiotic Duration:

• Standard duration: 3-5 days after successful biliary drainage 5, 6
• Short duration (4 days) is noninferior to conventional duration (8 days) for moderate-to-severe cholangitis 6
• Extended duration (2 weeks): For Enterococcus or Streptococcus to prevent infectious endocarditis 2
• Longer courses: Consider in cases of residual stones or ongoing obstruction 5

2. Biliary Decompression (Definitive Treatment)

ERCP is the first-line treatment for biliary decompression 2, 5

Timing of Intervention:

• Severe cholangitis (Grade III): Urgent ERCP with biliary drainage 5
• Moderate cholangitis (Grade II): Early decompression within 24 hours 5
• Mild cholangitis (Grade I): May tolerate delayed approach if responding to antibiotics, typically within 72 hours 4

Endoscopic Options:

• Nasobiliary drain placement with endoscopic sphincterotomy 2, 5
• Biliary stent placement (equally effective as nasobiliary drain; associated with less post-procedure discomfort) 2
• Endoscopic sphincterotomy with stone extraction (preferred in patients responding to antibiotics) 3
• Stent placement with or without sphincterotomy (safest option in ongoing sepsis with multiple large stones) 3

Prophylactic Antibiotics for ERCP:

Administer prophylactic antibiotics before ERCP, especially when incomplete drainage is anticipated 2

3. Alternative Drainage Approaches

Percutaneous Transhepatic Biliary Drainage (PTBD):

Reserve PTBD for patients in whom ERCP fails or is not feasible (unsuccessful biliary cannulation, inaccessible papilla) 2, 5

• PTBD carries higher complication risks including biliary peritonitis, hemobilia, pneumothorax, hematoma, liver abscesses 2

Open Surgical Drainage:

Use only when endoscopic or percutaneous approaches are contraindicated or unsuccessful 2, 5

• Emergency surgery for severe cholangitis carries high mortality rates 2
• Endoscopic drainage is preferred given shorter hospitalization and fewer serious complications 2

4. Supportive Care

• Fluid resuscitation: Aggressive IV hydration 3, 4
• Correction of coagulopathy 3
• ICU admission: For severe cholangitis with septic shock or organ dysfunction 5
• Vasopressor support: As needed for hemodynamic instability 4

5. Monitoring and Follow-up

• Monitor bilirubin levels to assess response to treatment 5
• Clinical reassessment: Evaluate for fever resolution, improvement in mental status, hemodynamic stability 4
• Repeat imaging: If no clinical improvement or worsening despite treatment 2
• Evaluate for definitive treatment of underlying cause (cholecystectomy for choledocholithiasis, evaluation for malignancy) 3

6. Special Considerations

Recurrent Cholangitis:

• Long-term prophylactic antibiotics: Consider in patients with compromised biliary systems (endoprosthesis, hepaticojejunostomy) 7
• Liver transplantation evaluation: For patients with recurrent cholangitis 5

Dominant Strictures in PSC:

• Endoscopic dilatation with or without stenting 5
• Brush cytology and/or endoscopic biopsy: Perform to exclude malignancy prior to therapy 5

Post-operative Cholangitis:

• Localized abscesses: Antibiotics and/or percutaneous drainage when no generalized peritonitis 2
• Generalized peritonitis: Prompt surgical source control 2

COMMON PITFALLS TO AVOID

• Delaying antibiotic administration in severe cases increases mortality; start within 1 hour for septic shock 5
• Failure to achieve adequate biliary drainage is associated with poor outcomes 5
• Overlooking fungal infection in patients not responding to antibiotic therapy 5
• Underestimating need for ICU admission in severe cholangitis 5
• Performing ERCP without expert multidisciplinary assessment in complex cases 2
• Unnecessarily prolonged antibiotic courses when adequate drainage achieved 6