What is the comprehensive overview of cholangitis (inflammation of the bile duct)?

From the Guidelines

Cholangitis is a life-threatening infection of the bile ducts that requires immediate antimicrobial treatment and biliary decompression, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary drainage in patients with moderate to severe disease 1.

Overview of Cholangitis

Cholangitis is an infectious disease characterized by acute inflammation and infection in the bile ducts, resulting from a combination of biliary obstruction and bacterial growth in bile. The most common cause of cholangitis is choledocholithiasis, which is the presence of gallstones in the bile ducts 1.

Clinical Presentation and Diagnosis

The clinical presentation of cholangitis varies and can include symptoms such as fever, abdominal pain, jaundice, and sometimes confusion or low blood pressure in severe cases. Diagnosis involves blood tests showing elevated white blood cells, liver enzymes, and bilirubin, along with imaging studies such as ultrasound, CT scan, or MRCP to identify blockages 1.

Treatment

Treatment of cholangitis requires prompt administration of antibiotics, typically starting with broad-spectrum options, and biliary drainage to remove the obstruction and allow bile to flow freely. ERCP is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis, as it has been shown to have lower morbidity and mortality compared to open surgical drainage 1.

Biliary Drainage Options

There are various endoscopic transpapillary options available, including biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy, all of which have their appropriate indications corresponding to disease severity and clinical context 1. Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails, and 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.

Importance of Prompt Treatment

Without proper treatment, cholangitis can progress to sepsis, liver abscess, or even death, which is why rapid intervention is essential. Recurrent episodes may indicate the need for definitive treatment of underlying causes, such as cholecystectomy for gallstone disease or stent placement for strictures.

Key Points

• Cholangitis is a life-threatening infection of the bile ducts that requires immediate treatment.
• ERCP is the preferred method for biliary drainage in patients with moderate to severe disease.
• Prompt administration of antibiotics and biliary drainage are crucial for treatment.
• Percutaneous biliary drainage and open drainage are alternative options when ERCP is not possible or has failed.

From the Research

Definition and Types of Cholangitis

• Cholangitis is a serious life-threatening situation affecting the hepatobiliary system 2
• It can be categorized as primary sclerosing (PSC), secondary (acute) cholangitis, and IgG4-associated cholangitis (IAC) 2

Etiology and Pathogenesis

• The etiology and pathogenesis of cholangitis are heterogeneous 2
• Roles of genetic and acquired factors have been noted in the development of various forms of cholangitis 2
• Bacterial infections are known as the most common cause for acute cholangitis (AC) 2, 3
• IAC has been commonly encountered along with pancreatitis 2

Diagnosis and Treatment

• Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis 2
• Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography comprise three of the modalities that are frequently exploited as both diagnostic and therapeutic tools 2
• Biliary drainage procedures using these methods are necessary for controlling the progression of cholangitis 2
• Promising results have been reported for the role of antibiotic treatment in the management of AC and PSC 2
• Immunosuppressive drugs have also rendered clinical responses in IAC 2
• Surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed 2

Acute Cholangitis

• Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts 3
• It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15% 3
• New data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis 3
• Different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures have been proposed 3

Timing of ERCP

• Performing emergent ERCP within 48 hours in patients with acute cholangitis is associated with lower in-hospital mortality, 30-day mortality, organ failure, and shorter length of stay 4
• ERCP performed within 6 or 12 hours of presentation was not associated with superior clinical outcomes, however, may result in reduced re-hospitalization 5
• The optimal timing of biliary drainage by ERCP for patients with acute cholangitis remains controversial 5

Antibiotic Prophylaxis

• The use of prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) is recommended by all major international gastroenterological societies, especially in the presence of an obstructed biliary system 6
• Prophylactic antibiotics reduce bacteriaemia and seem to prevent cholangitis and septicaemia in patients undergoing elective ERCP 6
• Further research is required to determine whether antibiotics can be given during or after an ERCP if it becomes apparent that biliary obstruction cannot be relieved during that procedure 6