What is the management for cholangitis?

Management of Cholangitis

The management of acute cholangitis requires immediate broad-spectrum antibiotics combined with urgent biliary drainage for moderate-to-severe cases, as biliary decompression is the definitive treatment that reduces mortality from nearly 100% historically to 2.7-10% today. 1, 2

Immediate Antibiotic Therapy

Timing is critical for antibiotic administration:

• Start antibiotics within 1 hour if septic shock is present 1, 2, 3
• Start within 4 hours for patients without shock to allow time for diagnostic studies 1, 3
• Always initiate before any drainage procedures 1

Recommended empiric regimens include: 1, 2, 3

• Piperacillin/tazobactam
• Imipenem/cilastatin or meropenem
• Ertapenem
• Aztreonam (with amikacin if shock present)
• Add fluconazole in fragile patients or delayed diagnosis 1

Duration of antibiotic therapy: 1, 2, 3

• 4 days after successful biliary drainage (per Tokyo Guidelines)
• 2 weeks if Enterococcus or Streptococcus isolated (to prevent infectious endocarditis) 1, 2
• Extend until anatomical resolution if residual stones or ongoing obstruction present 1, 3
• Some evidence supports only 3 days post-drainage may be sufficient 1

Biliary Drainage: The Definitive Treatment

Endoscopic retrograde cholangiopancreatography (ERCP) is first-line for biliary decompression: 1, 2, 3, 4

• Success rate exceeds 90% with adverse events <5% and mortality <1% 1
• Perform urgent drainage for severe (Grade III) cholangitis 2, 3
• Perform early drainage within 24 hours for moderate (Grade II) cholangitis 3
• Mild (Grade I) cases may respond to antibiotics alone but require definitive therapy later 4

ERCP options include: 1, 3

• Endoscopic sphincterotomy with stone extraction (preferred if patient stable)
• Biliary stent placement
• Nasobiliary drain placement (allows repeated bile aspiration for cultures and flushing) 1

Alternative drainage when ERCP fails or is not feasible: 1, 3, 4

• Percutaneous transhepatic biliary drainage (PTBD) - second-line option 3, 4
• EUS-guided biliary drainage (emerging technique requiring standardization) 1
• Surgical drainage - reserved only when endoscopic/percutaneous approaches fail 3, 5

Severity Assessment and Risk Stratification

Use Tokyo Guidelines 2018 classification: 2

• Grade III (Severe): Organ dysfunction present - requires urgent drainage
• Grade II (Moderate): High-risk factors present - requires early drainage within 24 hours
• Grade I (Mild): May respond to antibiotics alone initially

Obtain bile cultures during drainage procedures to guide antibiotic therapy, as bile cultures are positive in 59-93% of cases 1, 3

Special Considerations for Recurrent Cholangitis

For patients with recurrent bacterial cholangitis: 1

• Consider prophylactic long-term antibiotics 1
• Evaluate for liver transplantation if refractory to medical management 1, 3
• In PSC patients with dominant strictures, endoscopic dilatation is preferred over stent insertion 1

Surgical Management for Stone-Related Cholangitis

Laparoscopic common bile duct exploration (LCBDE) considerations: 2

• Suitable for mild-to-moderate cholangitis only
• Avoid in severe cholangitis, especially in patients >80 years old due to high mortality 2
• Comparable stone clearance rates to ERCP (91.7% vs 88.1%) 1, 2
• Offers shorter hospital stays and lower recurrence rates (2.06% vs 9.47%) compared to ERCP + cholecystectomy 2

Critical Pitfalls to Avoid

Common errors that worsen outcomes: 2, 3

• Delaying antibiotic administration beyond recommended timeframes increases mortality 2, 3
• Failing to achieve adequate biliary drainage - antibiotics alone are insufficient for moderate-to-severe disease 1, 4
• Attempting early surgical intervention in severe cholangitis, particularly in elderly patients 2
• Not extending antibiotic duration when residual stones or obstruction persist 1, 3
• Overlooking fungal infection in patients not responding to standard therapy 3