What is the severity grading and treatment approach for acute cholangitis?

Acute Cholangitis Severity Grading

Acute cholangitis is stratified into three severity grades (Grade I-III) using the Tokyo Guidelines criteria, which directly determine the urgency of biliary drainage: Grade I (mild) responds to antibiotics alone, Grade II (moderate) requires early drainage within 24 hours, and Grade III (severe) demands urgent drainage after hemodynamic stabilization. 1, 2

Severity Classification System

Grade I (Mild) Acute Cholangitis

• Defined as acute cholangitis that responds to initial medical treatment with clinical improvement 3
• Patients do not have organ dysfunction and show improvement with antibiotics alone 2
• Initial medical management with broad-spectrum antibiotics is sufficient for most cases 4
• Biliary drainage should be considered only for non-responders to initial medical treatment 4

Grade II (Moderate) Acute Cholangitis

• Characterized by the presence of any two of the following prognostic factors: 5
  • Abnormal WBC count
  • High fever (≥39°C)
  • Age ≥75 years
  • Hyperbilirubinemia (total bilirubin ≥5 mg/dL)
  • Hypoalbuminemia
• No organ dysfunction is present, but the patient does not respond to initial medical treatment within 12-24 hours 5, 3
• Early biliary drainage within 24 hours is mandatory and significantly reduces 30-day mortality 1, 2

Grade III (Severe) Acute Cholangitis

• Defined by the presence of at least one new-onset organ dysfunction: 5, 3
  • Cardiovascular dysfunction: Hypotension requiring dopamine ≥5 μg/kg/min or any dose of norepinephrine
  • Neurological dysfunction: Disturbance of consciousness
  • Respiratory dysfunction: PaO2/FiO2 ratio <300
  • Renal dysfunction: Oliguria or serum creatinine >2.0 mg/dL
  • Hepatic dysfunction: PT-INR >1.5
  • Hematological dysfunction: Platelet count <100,000/mm³
• Requires appropriate organ support and urgent biliary drainage after hemodynamic stabilization 1, 4

Diagnostic Criteria

Clinical Manifestations (Charcot's Triad)

• Fever and/or chills 3
• Abdominal pain in the right upper quadrant or epigastrium 3
• Jaundice 3

Supporting Evidence for Definite Diagnosis

• Laboratory data showing inflammation: Elevated WBC count or CRP 5
• Imaging demonstrating biliary obstruction or dilatation 5
• A definite diagnosis can be made when not all components of Charcot's triad are present if laboratory and imaging findings support inflammation and biliary obstruction 3

Treatment Algorithm Based on Severity

Antibiotic Administration Timing

• Septic shock cases: Initiate broad-spectrum antibiotics within 1 hour of diagnosis 1, 2
• Non-septic cases: Administer antibiotics within 4-6 hours of diagnosis 2, 5
• Broad-spectrum coverage targeting Gram-negative enteric bacteria is essential 1
• Empiric options include piperacillin/tazobactam or carbapenems for community-acquired infections 5

Biliary Drainage Strategy by Grade

Grade I (Mild):

• Initial observation with medical treatment is appropriate 2
• Many patients respond to antibiotics alone without requiring emergent intervention 2
• Elective drainage can be performed after clinical improvement if needed 2
• Treatment for underlying etiology (such as endoscopic sphincterotomy for choledocholithiasis) might be performed simultaneously with drainage if possible 4

Grade II (Moderate):

• Early biliary drainage within 24 hours is required and significantly reduces 30-day mortality compared to delayed drainage 1, 2
• The 24-hour window is critical for optimal outcomes, and delayed drainage significantly increases mortality 1
• ERCP with stent placement is the procedure of choice based on superior safety and efficacy 1, 2

Grade III (Severe):

• Urgent biliary drainage is required after hemodynamic stabilization with appropriate organ support 1, 2
• Focus should be solely on decompression with minimal biliary manipulation 1, 2
• Attempting definitive treatment during the acute phase increases morbidity 1
• ERCP with stent placement remains the preferred approach 1, 2

Drainage Modality Selection

• ERCP with stent placement is the procedure of choice, demonstrating superior safety and effectiveness with the lowest risk of adverse events 2
• ERCP-related complications include pancreatitis (3.5%), hemorrhage (1.3%), and post-ERCP cholangitis (<1%) 1, 2
• Percutaneous Transhepatic Biliary Drainage (PTBD) is reserved for patients who have failed ERCP or have difficult anatomy 1, 2
• Open surgical drainage should be avoided due to widespread availability of less invasive techniques 2

Antibiotic Duration

• 3 days post-drainage with successful biliary drainage 5
• 7-10 days for standard acute cholangitis treatment 1
• Consider extending to 2 weeks if Enterococcus or Streptococcus is isolated to prevent infectious endocarditis 1
• Continue until anatomical resolution in cases with incomplete drainage or residual stones 5

Critical Pitfalls to Avoid

• Delayed drainage in Grade II cholangitis significantly increases mortality—the 24-hour window is critical 1
• In severe cholangitis, attempting definitive treatment during the acute phase increases morbidity 1
• All patients require fluids, correction of coagulopathies, and appropriate antimicrobial therapy regardless of severity 1
• Risk-benefit assessment for ERCP is essential, but the endoscopic approach remains the safest option 1