From the Guidelines
The primary treatment for acute cholangitis is endoscopic retrograde cholangiopancreatography (ERCP) with biliary decompression, which should be performed as soon as possible to reduce morbidity and mortality. This approach is supported by the 2017 WSES guidelines for management of intra-abdominal infections, which recommend ERCP as the treatment of choice for biliary decompression in patients with moderate to severe acute cholangitis 1.
Key Elements of Therapy
The key elements of therapy in acute cholangitis include:
- Adequate antimicrobial treatment to avoid or manage septic complications
- Biliary decompression to restore biliary drainage in case of obstruction
- Initial risk stratification to guide further management
Antimicrobial Treatment
Antibiotic treatment should be initiated empirically as early as possible in any patient with a clinical suspicion of cholangitis, with options including piperacillin-tazobactam or ciprofloxacin plus metronidazole 1. The duration of antibiotic treatment depends on the resolution of the anatomical alteration, with a minimum of 3-5 days in the setting of successful ERCP drainage.
Biliary Decompression
ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, with various endoscopic transpapillary options available, including biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy 1. Percutaneous transhepatic cholangiography (PTC) should be reserved for patients in whom ERCP fails, and open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or has been unsuccessfully performed.
Clinical Context
The clinical presentation of acute cholangitis varies, and initial risk stratification is important to guide further management. Severe cholangitis requires an early interventional approach, with the type and timing of biliary drainage based on the severity of the clinical presentation and the availability and feasibility of drainage techniques 1.
Outcome
The goal of treatment is to reduce morbidity and mortality, and improve quality of life, by promptly relieving biliary obstruction and managing septic complications. With prompt and effective treatment, patients with acute cholangitis can experience significant improvement in symptoms and outcomes.
From the Research
Treatment Overview
- The treatment for acute cholangitis typically involves a combination of antibiotic therapy and biliary drainage 2, 3, 4, 5.
- Antibiotic therapy should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available 3, 4.
- The choice of antibiotics may include broad-spectrum penicillins, which have been shown to be effective in treating acute cholangitis 6.
Biliary Drainage
- Biliary drainage is a crucial component of treatment for acute cholangitis, and can be achieved through endoscopic, percutaneous, or surgical methods 2, 3, 4.
- Endoscopic drainage is often the preferred method, particularly for patients with choledocholithiasis 4.
- Transhepatic biliary drainage may be used as an alternative if endoscopic drainage is not possible or has failed 4.
Supportive Care
- Supportive care, including fluid resuscitation and correction of coagulopathy, is also an important aspect of treatment for acute cholangitis 4, 5.
- Patients with acute cholangitis may require close monitoring and prompt intervention to prevent complications and improve outcomes 3, 4, 5.
Antibiotic Duration
- The optimal duration of antibiotic therapy for acute cholangitis is unclear, but fever-based antibiotic therapy has been shown to be safe and effective in some studies 2.
- Antibiotic therapy may be discontinued when the patient's clinical symptoms have resolved, such as when the body temperature is less than 37°C for 24 hours 2.