What are the interventions for Cholangitis (inflammation of the bile duct)?

From the Guidelines

Cholangitis intervention requires prompt antibiotic therapy and biliary decompression, with endoscopic retrograde cholangiopancreatography (ERCP) being the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis. The management of acute cholangitis involves a combination of adequate antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction 1. The clinical presentation varies, and initial risk stratification is important to guide further management 1.

Key Elements of Therapy

• Adequate antimicrobial treatment to avoid or manage septic complications
• Biliary decompression to restore biliary drainage in case of obstruction
• ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 1
• Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails 1
• Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1

Antibiotic Therapy

Antibiotic agents should be initiated empirically as early as possible in any patient with a clinical suspicion of cholangitis, with options including broad-spectrum antibiotics like piperacillin-tazobactam or a combination of ceftriaxone and metronidazole 1. The importance of the quality of biliary drainage is highlighted by a study demonstrating that, in the setting of successful ERC drainage, the clinical results were the same after 3 versus 5 days of antibiotic treatment 1.

Biliary Decompression

Biliary decompression should be performed within 24-48 hours, typically via ERCP with stone extraction and/or stent placement 1. For critically ill patients, immediate decompression may be necessary. Fluid resuscitation with crystalloids and hemodynamic support are essential components of management. Pain control with opioid analgesics should be provided as needed. Antibiotics should continue for 4-7 days total, with longer courses for complicated infections. The intervention is urgent because bacterial translocation in obstructed bile ducts can rapidly lead to sepsis. After resolution, addressing the underlying cause (stones, strictures, malignancy) is necessary to prevent recurrence. Patients should be monitored closely for clinical improvement with vital signs, laboratory values, and clinical assessment to ensure resolution of the infection.

From the Research

Interventions for Cholangitis

The interventions for cholangitis include:

• Early recognition and treatment with broad-spectrum antibiotics, fluid resuscitation, and surgical or endoscopic intervention 2
• Administration of broad-spectrum antibiotics to cover both gram-negative and gram-positive organisms associated with cholangitis 3
• Biliary decompression, which can be achieved through endoscopic or percutaneous methods 3, 4
• Endoscopic options such as endoscopic papillotomy (EP) and extraction of stones, or the placement of a biliary drainage system 3
• Transhepatic biliary drainage as an alternative to endoscopic drainage in cases of failure or suspected hilar cholangiocarcinoma or intrahepatic stones 3
• Surgical biliary decompression, which is seldom required in the emergency setting but plays an important role in the definitive treatment of the underlying cause 3

Choice of Antibiotics

The choice of antibiotics for cholangitis includes:

• Broad-spectrum penicillins such as piperacillin, which have been shown to be effective in treating acute cholangitis 5
• Cefmetazole, which may be an alternative to carbapenems and piperacillin/tazobactam as initial therapy for bacteremic acute cholangitis 6
• Carbapenems and piperacillin/tazobactam, which are commonly used to treat extended-spectrum β-lactamase (ESBL)-producing Enterobacterales in acute cholangitis 6

Timing and Approach to Biliary Decompression

The timing and approach to biliary decompression in cholangitis include:

• Biliary decompression within 48 hours of diagnosis, as suggested by the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee 4
• Endoscopic rather than percutaneous drainage, as suggested by the ASGE 4
• Sphincterotomy and stone removal combined with drainage, rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment 4