Treatment

Initial management of patients with suspected acute cholangitis involves: (1,2)

• admission to hospital and basic resuscitation
  • patient should be on fasting with sufficient intravenous hydration, antimicrobial and analgesic agents, along with the monitoring of respiratory hemodynamic conditions in preparation for emergency drainage

Key aims of treatment are:

• to tackle infection with appropriate antibacterial therapy
  • most cases of cholangitis are initially treated with empirical antibacterial therapy that will cover Gram-positive and Gram-negative aerobic bacteria, as well as anaerobic bacteria such as a broad-spectrum second- or third-generation cephalosporin plus metronidazole
  • for patients allergic to penicillin, the combination of a quinolone, such as ciprofloxacin or levofloxacin plus metronidazole is often used
  • note that the initial antibacterial regimen may need to be altered in light of blood culture results
• to relieve the obstruction by biliary drainage.
  • acute cholangitis patients who fail to respond to antibiotic therapy and those with signs of septic shock require biliary decompression
  • the timing of such drainage depends on the severity of cholangitis, and on the patient's overall clinical state and response to antibacterial and supportive therapy
  • drainage is achieved by
    • ERCP - is the method of choice for biliary drainage with bile duct drainage or clearance, successful in more than 90% of cases
    • PTC
    • open surgery - rarely used as the first-line method of biliary drainage now due to its high mortality rate
  • patients who respond to antibiotic therapy will ultimately require surgical intervention for aetiology which can be planned on an elective basis

In elderly patients or those with untreated neoplastic obstruction, it may be advisable to drain the duct by non-operative means so that a definitive operation can be done electively when the general health of the patient has improved. Cholangitis accompanying neoplastic obstruction may be managed by inserting a transhepatic drainage catheter into the bile duct. Those patients with choledocholithiasis may be treated by emergency endoscopic sphincterotomy and insertion of a T-tube.

TG13 guideline recommendations for management of acute cholangitis:

• when acute cholangitis is suspected, diagnostic assessment is made using TG13 diagnostic criteria every 6–12 h
• abdominal X-ray (KUB) and abdominal US are carried out, followed by CT scan, MRI, MRCP and HIDA scan
• severity is repeatedly assessed using severity assessment criteria for acute cholangitis of TG 13; at diagnosis, within 24 h after diagnosis, and during the time zone of 24–48 h
• as soon as a diagnosis has been made initial medical treatment is provided - nil per mouth (NPO), IV fluid, antimicrobial and analgesia together with close monitoring of blood pressure, pulse, and urinary output
• appropriate treatment in accordance with the severity grade
  • `Grade I (mild) acute cholangitis
    • antibiotic and general supportive care
      • if no response within 24 hours - biliary drainage should be considered
    • endoscopic , percutaneous or operative intervention for aetiology of acute cholangitis once acute illness has resolved
  • Grade II (moderate) acute cholangitis
    • early endoscopic or percutaneous drainage (or even emergency operative drainage with a T-tube)
    • antibiotics and general supportive care
    • endoscopic , percutaneous or operative intervention for aetiology of acute cholangitis once acute illness has resolved
  • Grade III (severe) acute cholangitis
    • appropriate organ support e.g. - ventilatory/circulatory management
    • urgent biliary drainage with endoscopic or percutaneous drainage (or even emergency operative drainage with a T-tube)
    • antibiotics and general supportive care
    • endoscopic , percutaneous or operative intervention for aetiology of acute cholangitis once acute illness has resolved
• frequent reassessment and if required reclassification of patients based on the response to initial medical treatment
• blood culture and/or bile culture is performed for Grade II (moderate) and III (severe) patients

References:

1. Miura F, Okamoto K, Takada T, et al. Tokyo guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40.
2. Buxbaum JL, Buitrago C, Lee A, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021 Aug;94(2):207-21.