Acute Cholangitis

Background

• Acute cholangitis is an inflammation of the biliary tree, most commonly caused by bacterial infection in the setting of biliary stasis or obstruction.
• Choledocholithiasis is the most common cause, but other common etiologies include both malignant and benign (such as post-procedural) stenosis.
• Severity ranges from a self-limited to a potentially life-threatening disease requiring urgent management.
  • The classic symptoms include the Charcot triad of fever, abdominal pain, and jaundice, which are highly specific but not as sensitive as the Tokyo guidelines published in 2018.
  • Nausea and vomiting may also be presenting symptoms, and patients with severe cholangitis may have the Reynold pentad, which includes the Charcot triad plus septic shock and an altered mental status.
• Infecting organisms are enteric in origin and may include gram-negative rods (such as Escherichia coli or Klebsiella spp.), as well as gram-positive organisms such as Enterococcus spp., and anaerobes.

Evaluation

• Suspect acute cholangitis in patients presenting with fever, shaking chills, jaundice, and/or abdominal pain, typically right-upper quadrant pain. The diagnosis is still only suspected in the presence of systemic inflammation plus either cholestasis or compatible imaging findings.
• Cholangitis can be diagnosed in the presence of systemic inflammation plus cholestasis plus compatible imaging findings (Strong recommendation).
  • Systemic inflammation can be demonstrated by any of
    • fever and/or shaking chills,
    • abnormal white blood cell count, or
    • an elevated C-reactive protein.
  • Cholestasis can be demonstrated by any of
    • jaundice or total bilirubin ≥ 2 mg/dL (34.2 mcmol/L), or
    • > 1.5 times the upper limit of normal values for alkaline phosphate, gamma-glutamyl transferase, alanine aminotransferase, or aspartate aminotransferase.
  • Compatible imaging findings include either
    • intrahepatic biliary dilatation or
    • visualization of stricture, stone, stent, or other cause of obstruction.
• Initial laboratory testing for suspected cholangitis should include
  • complete blood count
  • liver chemistries
  • C-reactive protein
  • blood cultures (particularly if moderate or severe)
• Ultrasound is the recommended initial imaging choice in all patients and may help differentiate intra and extrahepatic obstruction. Magnetic resonance cholangiopancreatography (MRCP) is more sensitive and may be help plan procedural interventions.
• Endoscopic retrograde cholangiopancreatography (ERCP) is useful for both diagnosis and treatment, as it may potentially drain the biliary tree and retrieve biopsy or culture specimens. If obtained, a biliary culture can be helpful in guiding antibiotic management.
• After establishing the diagnosis, the immediate and accurate assessment of severity is critical to management (Strong recommendation).
• Severity of the initial presentation of acute cholangitis is divided into
  • mild, in which cholangitis is present but does not meet criteria for moderate or severe
  • moderate, defined as the presence of any two of
    • age > 75 years
    • white blood cell count of > 12,000/mcL or < 4,000/mcL
    • fever > 39 degrees C (102.2 degrees F)
    • total bilirubin ≥ 5 mg/dL [85.5 mcmol/L]
    • serum albumin < 0.7 x lower limit of normal
  • severe, defined as any organ dysfunction, such as
    • hypotension
    • altered consciousness
    • PaO₂/FiO₂ < 300
    • serum creatinine > 2 mg/dL or oliguria
    • international normalized ratio of > 1.5 (evidence of liver dysfunction)
    • platelet count < 100,000/mcL

Management

• Empiric broad-spectrum antibiotics are indicated for all patients with definite or suspected cholangitis (Strong recommendation), consider giving antibiotics and/or intravenous fluid as soon as possible if indicated.
  • For patients with mild-to-moderate community-acquired disease, recommended options include cefazolin, cefuroxime, or ceftriaxone (Strong recommendation).
  • For patients with severe physiologic disturbance, advanced age, immunocompromise, or infection following bilioenteric anastomosis, recommended empiric regimens include a combination of (Strong recommendation):
    • metronidazole PLUS
    • piperacillin-tazobactam, cefepime, ciprofloxacin, levofloxacin, imipenem-cilastatin, doripenem, ertapenem, or meropenem
  • For patients with a healthcare-associated biliary infection, vancomycin should be added to the above regimens (Strong recommendation).
  • Biliary and blood culture results may be useful to help guide antibiotic therapy.
• Biliary drainage depends on the assessment of disease severity, which may change after the initial evaluation:
  • Grade I (mild) - drainage not needed in most patients, but consider for patients unresponsive to antibiotics and supportive care
  • Grade II (moderate) - early endoscopic, percutaneous, or operative drainage for all patients
  • Grade III (severe) - urgent endoscopic, percutaneous, or operative drainage for all patients
  • Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice (Strong recommendation).
  • Percutaneous drainage may be considered if endoscopic drainage is impossible (due to an upper gastrointestinal (GI) tract obstruction or a lack of specialist availability), unsuccessful, or if the patient is unstable (Weak recommendation).
  • Surgical drainage is rarely needed for benign disease (such as gallstones), and is most commonly performed in patients with cholangitis due to extensive neoplastic disease.