From the Guidelines
Cholangitis requires immediate medical attention with intravenous antibiotics and biliary drainage within 24-48 hours, typically via endoscopic retrograde cholangiopancreatography (ERCP), to prevent sepsis, shock, and multi-organ failure. The most recent and highest quality study 1 recommends that the key elements of therapy in acute cholangitis are adequate antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction.
Treatment Approach
The treatment approach should involve:
- Intravenous antibiotics such as piperacillin-tazobactam (3.375g every 6 hours), ciprofloxacin (400mg every 12 hours) plus metronidazole (500mg every 8 hours), or a third-generation cephalosporin with metronidazole, started immediately after blood cultures are drawn 1
- Fluid resuscitation and pain management as essential supportive measures
- Biliary drainage within 24-48 hours, typically via ERCP, to remove the obstruction causing the infection 1
Biliary Drainage Options
The options for biliary drainage include:
- Endoscopic retrograde cholangiopancreatography (ERCP) as the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1
- Percutaneous transhepatic cholangiography (PTC) as an alternative option when ERCP fails 1
- Open surgical drainage only in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1
Importance of Early Intervention
Early intervention is crucial in the management of acute cholangitis, as delayed treatment can lead to sepsis, shock, and multi-organ failure 1. The study by 1 highlights the importance of prompt biliary drainage and antimicrobial treatment in improving outcomes in patients with acute cholangitis.
Underlying Cause
After resolution of the infection, addressing the underlying cause is crucial to prevent recurrence, which may involve gallstone removal, stent placement, or surgery depending on the etiology 1.
From the Research
Definition and Diagnosis 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 the most common cause of acute cholangitis (AC) 2
- Imaging evaluation of the hepatobiliary system, including endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography, is crucial in the management of cholangitis 2
Treatment of Cholangitis
- The current management of acute cholangitis consists of antibiotic therapy in combination with biliary drainage 3
- Endoscopic biliary drainage is a recommended approach for the management of cholangitis 4
- The American Society for Gastrointestinal Endoscopy (ASGE) suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours 4
- Antibiotic therapy, such as cefmetazole, carbapenems, and piperacillin/tazobactam, is effective in the treatment of acute cholangitis 3, 5
- The Tokyo Guidelines 2018 provide recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections 6
Antibiotic Therapy for Cholangitis
- Cefmetazole may be an alternative to carbapenems and piperacillin/tazobactam as initial therapy for bacteremic acute cholangitis 5
- Initial therapy with cefmetazole may contribute to a shorter length of stay and lower antibiotic costs than treatment with carbapenems and piperacillin/tazobactam, without worsening patient outcomes 5
- The duration of antimicrobial therapy for acute cholangitis should be systematically reviewed, and prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are important parts of decision-making 6