What are the guidelines for managing cholangitis?

Management of Cholangitis

Core Treatment Principles

The management of acute cholangitis requires immediate broad-spectrum antibiotics combined with biliary decompression, with ERCP being the preferred method for moderate-to-severe cases. 1, 2

The two fundamental pillars of cholangitis management are:

• Antimicrobial therapy to control sepsis and prevent complications 1, 2
• Biliary decompression to restore bile drainage when obstruction is present 1, 2

Antibiotic Therapy

Timing and Initiation

• Start broad-spectrum antibiotics within 1 hour in patients presenting with severe sepsis or shock 2
• In hemodynamically stable patients without shock, antibiotics may be delayed up to 6 hours to allow for diagnostic sampling 2

Antibiotic Selection

For mild cases:

• Fluoroquinolones (ciprofloxacin) are first-line agents 1, 2

For moderate-to-severe cases:

• Use intravenous cephalosporins or extended-spectrum penicillins with anaerobic coverage 1, 2
• Coverage must include gram-negative aerobic enteric organisms (E. coli, Klebsiella, Enterobacter), gram-positive Enterococcus, and anaerobic bacteria (Bacteroides fragilis, Clostridium perfringens) 2

Duration of Antibiotic Therapy

The optimal duration is 4 days after successful biliary decompression 2. This represents the most recent high-quality evidence:

• A 2024 randomized noninferiority trial demonstrated that 4 days of antibiotics after successful biliary drainage is noninferior to 8 days in patients with moderate-to-severe cholangitis, with clinical cure rates of 77.97% vs 79.66% respectively 3
• This shorter duration significantly reduces total antibiotic exposure (4.75 vs 8.58 days) without increasing recurrence, mortality, or hospitalization 3
• An alternative approach is fever-based therapy: discontinue antibiotics when body temperature remains <37°C for 24 hours after successful drainage 4

Important caveat: Malignant etiology and hypotension at presentation are associated with lower clinical cure rates and may require individualized duration 3

Biliary Decompression

Timing

• Urgent biliary decompression is essential for survival in severe cholangitis 1
• Patients who respond to initial antibiotic therapy can undergo more selective timing of intervention 5
• Those who fail to respond to conservative therapy require urgent decompression 5

Method Selection

ERCP is the treatment of choice for biliary decompression in moderate-to-severe acute cholangitis 1, 2:

• A randomized controlled trial demonstrated that endoscopic nasobiliary drainage (ENBD) plus endoscopic sphincterotomy (EST) has significantly lower morbidity and mortality compared to T-tube drainage via laparotomy in severe cholangitis with hypotension or altered consciousness 1, 2
• Endoscopic options include biliary stent placement or nasobiliary drain insertion above the obstruction site, with or without sphincterotomy 1
• Both nasobiliary catheter and indwelling stent are equally effective, though indwelling stents cause less post-procedure discomfort and avoid inadvertent removal 1

Percutaneous transhepatic biliary drainage (PTBD):

• Reserved for patients in whom ERCP fails due to unsuccessful biliary cannulation or inaccessible papilla 1, 2
• Associated with significant complications including biliary peritonitis, hemobilia, pneumothorax, hematoma, and liver abscesses 1

Open surgical drainage:

• Only used when both endoscopic and percutaneous approaches have failed or are contraindicated 2
• Rarely required in the emergency setting but may play a role in definitive treatment of underlying causes 5

Special Considerations in Primary Sclerosing Cholangitis (PSC)

Patients with PSC and cholangitis require specific management modifications:

• Antibiotic prophylaxis is mandatory for all patients with PSC undergoing ERCP 1, 2
• ERCP is a major risk factor for cholangitis in PSC patients, with bacterobilia reported in 55% at liver transplantation, increasing to 77% with predisposing factors 1
• The highest infection risk occurs when biliary stents are left in situ (98% positive bile culture rate vs 55% without stents) 1

For dominant strictures in PSC:

• Urgent biliary decompression is necessary when acute cholangitis develops 2
• Balloon dilation is preferred over biliary stenting during ERCP 2
• Patients should undergo multidisciplinary expert evaluation before ERCP intervention 6
• Pathologic sampling of suspicious strictures is mandatory during ERCP 6

Microbiology considerations in PSC:

• Candida species are isolated from bile in 12% of PSC patients undergoing ERCP 1
• Consider antifungal therapy in patients with cholangitis not responding to antibiotics 1

Common Pitfalls to Avoid

• Do not delay antibiotics in severe sepsis waiting for cultures—start within 1 hour 2
• Do not continue antibiotics beyond 4 days after successful drainage in responding patients, as this increases unnecessary antibiotic exposure without benefit 3
• Do not perform open surgical drainage as first-line therapy when endoscopic options are available 1, 2
• Do not leave biliary stents in situ long-term in PSC patients, as this dramatically increases infection risk 1
• Do not forget anaerobic coverage in severe cases, as biliary infections are often polymicrobial 1, 2