What are the symptoms and treatment options for acute ascending cholangitis?

From the Guidelines

Acute ascending cholangitis requires immediate medical attention with antibiotics, supportive care, and biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP) as the first line of treatment. The management of acute ascending cholangitis involves a combination of antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction 1. The clinical presentation varies, and initial risk stratification is important to guide further management 1.

Key Elements of Therapy

• Adequate antimicrobial treatment to avoid or manage septic complications
• Biliary decompression to restore biliary drainage in case of obstruction
• ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 1
• Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis (Recommendation 1A) 1

Biliary Decompression Options

• Endoscopic nasobiliary drainage (ENBD) + endoscopic sphincterotomy (EST)
• Biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy
• Percutaneous transhepatic cholangiography (PTC) should be reserved for patients in whom ERCP fails (Recommendation 1B) 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 (Recommendation 2C) 1

Importance of Early Intervention

In severe cholangitis, an early interventional approach is absolutely essential for survival 1. A randomized controlled trial (RCT) demonstrated that the morbidity and mortality of endoscopic nasobiliary drainage (ENBD) + endoscopic sphincterotomy (EST) were significantly lower than those of T-tube drainage under laparotomy 1.

Monitoring and Supportive Care

Patients should be monitored closely for signs of sepsis, including hypotension, tachycardia, and altered mental status. Fluid resuscitation and correction of electrolyte imbalances are essential supportive measures. Initial empiric antibiotic therapy should include coverage for gram-negative and anaerobic organisms.

From the Research

Definition and Causes of Acute Ascending Cholangitis

• Acute 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 2, 3, 4.
• The main predisposing factor for acute cholangitis is biliary obstruction of any cause, with choledocholithiasis being the most common cause 3, 5, 4.
• Other causes of biliary tree obstruction include benign and malignant biliary strictures 5.

Diagnosis of Acute Ascending Cholangitis

• Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 2, 3, 5, 4.
• The clinical Charcot triad criteria are often used to diagnose acute cholangitis, but the Tokyo Guidelines provide a more comprehensive approach to diagnosis and management 5, 4.
• The Tokyo Guidelines enable a more accurate diagnosis of acute cholangitis and facilitate the classification of disease as mild, moderate, or severe 4.

Treatment and Management of Acute Ascending Cholangitis

• Treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 2, 6, 3, 5, 4.
• Endoscopic biliary drainage is ultimately required to treat the underlying obstruction, and endoscopic retrograde cholangiopancreatography is a common drainage option 6, 5, 4.
• The American Society for Gastrointestinal Endoscopy (ASGE) suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours 6.
• Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes and reduce mortality and morbidity 2, 5.