Recommendations

Key Recommendations

Once the diagnosis of cholangitis is suspected, initial treatment consists of administration of broad-spectrum intravenous antibiotics and intravenous hydration. Obtaining blood cultures, stabilizing hemodynamic parameters, correcting electrolyte and coagulation abnormalities, and providing analgesia for pain control are also other priority interventions for these patients.[27]

Biliary decompression follows, carried out either emergently or in a less urgent time frame depending on the severity of illness.[27][37] Care is typically provided in a setting capable of intensive medical monitoring.

Management of sepsis

Cholangitis can quickly become an acute, septic, life-threatening infection if not identified and treated promptly. Consider sepsis if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[23]

Treatment should be started immediately if sepsis is suspected or confirmed.[24]

Follow local protocols for investigation and treatment of all patients with suspected sepsis, or those at risk of deterioration to sepsis.[24][25][26]

For more detail on when to suspect sepsis and on its management, see Sepsis in adults.

Antibiotic treatment

Intravenous broad-spectrum antibiotic therapy is started on admission. Once blood and bile culture results are available, antibiotics can be tailored to the known pathogens. Bacteria are usually gram-negative, but gram-positive bacteria and anaerobes are also implicated in cholangitis.

Piperacillin/tazobactam, imipenem/cilastatin, or cefepime plus metronidazole are reasonable initial choices. Metronidazole plus ciprofloxacin or levofloxacin, or gentamicin plus metronidazole, are alternative regimens for penicillin-allergic patients.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[38]

  • Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

  • Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Once biliary drainage has been achieved and the patient shows clinical improvement, consideration should be given to switching to oral antibiotics for the remainder of the antibiotic course.

Medical management

Attention must be given to several critical factors.[27][37] Patients will often require normal saline bolus fluid administration followed by maintenance fluids with monitoring for signs of fluid overload. Intravenous potassium and/or magnesium may be required as indicated by lab testing results.

Repletion of coagulation factors with fresh frozen plasma and platelets may be required in those with abnormal coagulation parameters (low platelets, elevated prothrombin time). Administer oxygen therapy as necessary. Monitor oxygen saturation (SaO₂) and fraction of inspired oxygen (FiO₂) the patient is receiving, with the aim of maintaining SaO₂ between 92% and 96% (or 88% to 92% if the patient is at risk of hypercapnic respiratory failure).[39][40][41]

Appropriate analgesics for pain management include morphine, hydromorphone, and fentanyl.

Biliary decompression: nonoperative

Biliary decompression and drainage are necessary to allow for clinical improvement.[22][27][42]

Recommended time frames vary according to severity:

  • Within 12 hours following admission: for patients with a deteriorating status (with persistent abdominal pain, hypotension despite intravenous fluid administration, fever >102°F [>39°C], worsening confusional state).[27][30]

  • Within 24 to 72 hours after admission: those for whom antibiotic treatment and medical management provide stability.[27][28][30][37]

Endoscopic retrograde cholangiopancreatography (ERCP) performed within 48 hours of admission is associated with lower 30-day mortality and shorter hospital stays than ERCP performed after 48 hours.[22]

ERCP with or without sphincterotomy and placement of a drainage stent allows for biliary tree decompression and stone extraction, and is the first-line therapy for acute cholangitis.[22][30]​​[42] For bile duct stones that are large or difficult to remove, endoscopic lithotripsy may be performed for stone fragmentation during endoscopy to facilitate endoscopic removal.[30][43]

  • Emergent ERCP performed within 48 hours of admission can improve outcomes.[44][45] Observational studies and subsequent meta-analyses have shown patients with cholangitis who had early ERCP have a lower risk of hospital mortality, fewer hospital readmissions, and a shorter length of hospital stay when compared with patients who had delayed ERCP, recognizing that some patients require stabilization prior to ERCP and that this also takes time.[44][45][46][47]

  • Historically, all patients with cholangitis were admitted to the hospital following ERCP. However, a significant number of patients may be able to be treated as outpatients after ERCP, once drainage has been achieved and antibiotics started.[48]

If ERCP is unsuccessful, endoscopic ultrasound-guided biliary drainage (EUS-BD) can be considered, if available.[34] In practice, EUS-BD is a highly specialized procedure and is unavailable in many centers. Other procedures, such as percutaneous transhepatic biliary drainage (PTBD) may be used instead. In addition, if the patient is hemodynamically unstable or cannot tolerate general anesthesia, or malignancy is suspected as the cause of biliary obstruction, PTBD is preferred to EUS-BD.[34] ERCP, EUS-BD, and PTBD can be utilized for the purposes of procedures such as common bile duct stone extraction and stent placement.[22][34] Other modalities for biliary drainage may be used in certain circumstances (e.g., post-Roux-en-Y gastric bypass).[34]

Endoscopic stent insertion by ERCP with decompression by aspiration is an option for patients too ill to undergo either ERCP with sphincterotomy or PTBD, or for those who do not obtain adequate drainage subsequent to performance of one or the other of those procedures.

Nasobiliary drains can also be used in this setting, but are difficult to place and often dislodge spontaneously.[42] While effective, nasobiliary drain placement is rarely performed in practice (as these patients can usually undergo endoscopic stenting).

Biliary decompression: surgery

Nonoperative procedures have largely replaced emergency surgery for accomplishing biliary decompression, owing to their superior risk-benefit ratio.[42] Mortality associated with surgical management of cholangitis ranges from 10% to 40% and has been correlated with disease severity.[22]

If adequate biliary decompression/drainage is not accomplished via nonoperative means, choledochotomy with T-tube placement or cholecystectomy with common bile duct exploration may need to be undertaken.[42] Patients with a deteriorating course of acute cholangitis are at significant risk of surgical morbidity (bleeding, tissue infection, abscess formation acutely; adhesion formation and small bowel obstruction more remotely) and mortality. Elective surgery in stabilized patients carries a much lower risk of morbidity and mortality compared with emergency surgery.

Subsequent medical and surgical care

Patients who develop cholangitis due to choledocholithiasis and undergo stone removal from the biliary tree should have subsequent cholecystectomy if cholelithiasis is present.[30] Patients without cholelithiasis or with prior cholecystectomy who are at low risk of recurrent cholangitis can be followed expectantly. Patients who appear well (i.e., without systemic signs of sepsis) can be treated and managed as outpatients following duct decompression via ERCP.

If primary sclerosing cholangitis (PSC) is present, it will almost always be identified on cholangiogram (obtained via ERCP or PTC). Patients with PSC should be referred to a hepatologist for formal evaluation and possible consideration for liver transplantation depending on the severity of disease and model for end-stage liver disease score. See Primary sclerosing cholangitis.

Patients with HIV cholangiopathy who undergo sphincterotomy should be followed for improvement in liver chemistries and symptoms and should be referred to an HIV specialist for long-term care.

Peripheral intravascular catheter: animated demonstration
Peripheral intravascular catheter: animated demonstration

How to insert a peripheral intravascular catheter into the dorsum of the hand.

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