From the Guidelines
Cholangitis requires immediate treatment with antibiotics and biliary drainage to prevent sepsis and improve outcomes, with endoscopic retrograde cholangiopancreatography (ERCP) being the preferred method for biliary decompression in patients with moderate to severe acute cholangitis. The management of cholangitis involves a combination of antimicrobial therapy and biliary drainage to restore bile flow and prevent further complications 1.
Key Elements of Therapy
- 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
- Percutaneous transhepatic cholangiography (PTC) should be reserved for patients in whom ERCP fails 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 1
Antibiotic Therapy
For empiric antibiotic therapy, piperacillin-tazobactam 3.375g IV every 6 hours, or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours are recommended regimens 1. Antibiotics should be continued for 4-7 days, with adjustment based on culture results.
Biliary Drainage
Urgent biliary decompression via ERCP should be performed within 24-48 hours of diagnosis. A randomized controlled trial 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 Follow-up
Patients should be monitored for signs of septic shock including hypotension, tachycardia, and altered mental status. After resolution, addressing the underlying cause (such as cholecystectomy for gallstones) is necessary to prevent recurrence.
From the Research
Definition and Causes 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
- Bacterial infections are known as the most common cause for acute cholangitis (AC) 2
- The etiology and pathogenesis of cholangitis are heterogeneous, with roles of genetic and acquired factors noted in development of various forms of cholangitis 2
Diagnosis of Cholangitis
- Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 3
- Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis, with endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography being frequently used as both diagnostic and therapeutic tools 2
Treatment and Management of Cholangitis
- The current management of acute cholangitis consists of antibiotic therapy in combination with biliary drainage 4
- Fever-based antibiotic therapy for acute cholangitis is safe and effective when resolution of fever is achieved following endoscopic biliary drainage 4
- The American Society for Gastrointestinal Endoscopy's (ASGE) suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours 5
- Treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 3
- Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcome of the disease 3