What is the recommended approach for grading and managing cholangitis?

Cholangitis Grading and Management

Severity Grading System

Cholangitis should be graded into three severity categories (Grade I/mild, Grade II/moderate, Grade III/severe) based on the presence of organ dysfunction and response to initial medical treatment, which directly determines the urgency and type of intervention required. 1

Grade I (Mild) Cholangitis

• Defined as acute cholangitis that responds to initial medical treatment with improvement in clinical findings 1
• No organ dysfunction present 1
• Clinical manifestations and laboratory data improve with antibiotics 1

Grade II (Moderate) Cholangitis

• Defined as acute cholangitis without organ dysfunction but that does NOT respond to initial medical treatment 1
• Clinical manifestations and/or laboratory data fail to improve despite antibiotics 1
• Requires escalation to biliary drainage 1

Grade III (Severe) Cholangitis

• Defined as acute cholangitis accompanied by at least one new-onset organ dysfunction 1
• Represents a life-threatening emergency requiring intensive care 2
• Demands urgent biliary decompression after hemodynamic stabilization 1

Diagnostic Criteria

Cholangitis can be diagnosed when Charcot's triad is present: fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice 1. When the complete triad is absent, diagnosis requires laboratory data and imaging findings supporting inflammation and biliary obstruction 1.

Management Algorithm by Severity Grade

Grade I (Mild) Management

• Initial medical treatment with antimicrobial agents is sufficient for most cases 3
• Fluoroquinolones such as ciprofloxacin are first-line for mild cases 4
• Antibiotics should cover gram-negative aerobic enteric organisms (E. coli, Klebsiella, Enterobacter), gram-positive Enterococcus, and anaerobic bacteria 4
• For non-responders to initial medical treatment, biliary drainage should be considered 3
• Treatment for underlying etiology (such as endoscopic sphincterotomy for choledocholithiasis) might be performed simultaneously with biliary drainage if possible 3

Grade II (Moderate) Management

• Early biliary drainage should be performed along with administration of antibiotics 3
• ERCP is the modality of choice for biliary decompression 4
• Biliary decompression should occur within 48 hours 5
• Cephalosporins or broad-spectrum penicillins with anaerobic coverage should be used 4
• Sphincterotomy and stone removal should be combined with drainage rather than decompression alone, unless patients are too unstable 5
• Treatment for underlying etiology should be performed after the patient's general condition improves 3

Grade III (Severe) Management

• Appropriate organ support (ventilatory/circulatory management) is required as the first priority 3, 6
• Broad-spectrum antibiotics must be started within 1 hour in patients with severe sepsis or shock 4
• After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed 3, 6
• ERCP with nasobiliary drainage (ENBD) and endoscopic sphincterotomy shows lower morbidity and mortality compared to T-tube drainage via laparotomy 4
• Percutaneous transhepatic biliary drainage (PTBD) should be reserved for patients who fail ERCP 4
• Open drainage is only used when endoscopic or percutaneous drainage is contraindicated or has failed 4

Antibiotic Duration

Antibiotic therapy should continue for 4 days after source control through biliary decompression 4. Treatment should be extended to 2 weeks when Enterococcus or Streptococcus is present to prevent infectious endocarditis 7.

Critical Pitfalls to Avoid

• Do not delay biliary drainage in Grade II or III cholangitis - waiting beyond 48 hours increases morbidity and mortality 5
• Do not attempt comprehensive stone clearance in unstable Grade III patients - initial decompression alone is appropriate until stabilization occurs 5
• In patients without shock, a 6-hour delay for diagnostic sampling is tolerable, but this window must be substantially shortened in severe sepsis 7
• Patients with PSC undergoing ERCP require antibiotic prophylaxis 7, 4