From the Guidelines
Ascending cholangitis is a serious bacterial infection of the bile ducts that requires prompt treatment with antibiotics and often biliary drainage, with ERCP being the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1.
Initial Management
Initial management includes:
- Fluid resuscitation
- Empiric broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours
- Urgent biliary decompression for severe cases Blood cultures should be obtained before starting antibiotics.
Diagnosis and Presentation
Patients typically present with Charcot's triad (fever, right upper quadrant pain, and jaundice), though the complete triad is present in only 50-75% of cases. The most common causative organisms are gram-negative bacteria like E. coli, Klebsiella, and Enterobacter species, as well as enterococci. Biliary obstruction is the underlying cause, often due to gallstones, strictures, or malignancy.
Definitive Treatment
Definitive treatment involves addressing this underlying obstruction through:
- ERCP
- Percutaneous transhepatic cholangiography (PTC)
- Surgery Antibiotics should be continued for at least 4-7 days, with longer courses for patients with bacteremia or ongoing biliary obstruction. Without prompt treatment, ascending cholangitis can progress to septic shock and has a mortality rate of 5-10%, which increases significantly if treatment is delayed 2.
Biliary Drainage
The type and timing of biliary drainage should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques. 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 Treatment
Administration of antibiotic agents should be initiated empirically as early as possible in any patient with a clinical suspicion of cholangitis. The importance of the quality of biliary drainage is highlighted by another study demonstrating that, in the setting of successful ERC drainage, the clinical results were the same after 3 versus 5 days of antibiotic treatment 2.
Recent Guidelines
Recent guidelines from the EASL clinical practice guidelines on sclerosing cholangitis recommend that a diagnosis of large duct PSC should be made in the presence of typical findings of sclerosing cholangitis on high-quality cholangiography and after exclusion of secondary causes 3, 4.
From the Research
Definition and Diagnosis of Ascending Cholangitis
- Ascending cholangitis, also referred to as acute cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction 5.
- Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 5.
Treatment and Management
- The treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 5.
- The American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours 6.
- The ASGE also suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment 6.
- Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis, and the Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections 7.