Recommendations
Urgent
Cholangitis can quickly become an acute, septic, life-threatening infection if not identified and treated promptly. Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[22][23][24] See Sepsis in adults.
Use a systematic approach, alongside your clinical judgement, for assessment; urgently consult a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis.[23][24][26][28]
Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
Start intravenous broad-spectrum antibiotic therapy on admission.[32]
Stabilise haemodynamic factors:
Often patients with acute cholangitis need bolus intravenous fluids followed by maintenance fluids.
See Key recommendations and Full recommendations sections for further supportive management.
Arrange for biliary decompression:
Prepare patient for urgent biliary decompression (i.e., within 24 hours of admission) if their condition is deteriorating despite initial medical management.[29][38] Evidence suggests outcomes such as mortality and duration of hospital stay are reduced if biliary decompression is performed early.[38][39]
The most common method first-line for biliary decompression is endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy, drainage stent placement, and stone extraction.[30][33][40]
Key Recommendations
Initial stabilisation
In addition to giving broad-spectrum intravenous antibiotics and intravenous hydration:[29]
Correct any electrolyte imbalances
Correct coagulation abnormalities
Give adequate analgesia.
Biliary decompression
Non-surgical methods:
ERCP with or without sphincterotomy and placement of a drainage stent.[33]
Percutaneous trans-hepatic cholangiography (PTC) - an option if ERCP is not suitable, or has not been adequately successful.
Consider endoscopic lithotripsy to facilitate endoscopic bile duct stone removal.[30][41]
Surgical methods:
Urgent surgery is usually avoided in the emergency setting and should be considered a last resort. Surgical approaches are usually laparoscopic and can include:
Choledochotomy with T-tube placement
Cholecystectomy with common bile duct exploration.
Elective surgery in patients who are clinically stable is preferred.
Switch to specific antibiotic regimen, guided by results
Once results are available for blood and bile cultures:
Switch antibiotics therapy from broad spectrum to a more specific regimen
Following biliary decompression, consider replacing intravenous antibiotic therapy with oral therapy as the patient’s clinical condition improves.
Ongoing management
Consider subsequent cholecystectomy for patients who had cholangitis with cholelithiasis.
Refer patients with primary sclerosing cholangitis (PSC) to a hepatologist.
Refer patients with HIV to an HIV specialist.
Continue to monitor symptoms and blood tests, including liver function.
Once the diagnosis of cholangitis is suspected, initial treatment consists of administration of broad-spectrum intravenous antibiotics and intravenous hydration. Prioritise obtaining blood cultures, stabilising haemodynamic parameters, correcting electrolyte and coagulation abnormalities, and providing analgesia for pain control.[13][29]
Biliary decompression follows, with this carried out either emergently or in a less urgent time frame depending on the severity of illness.[29][42] Care is typically provided in a setting capable of intensive medical monitoring.
Start intravenous broad-spectrum antibiotic therapy for all patients with suspected or confirmed cholangitis, with more specific treatment guided by results of blood and bile cultures.[32]
How to insert a peripheral venous cannula into the dorsum of the hand.
Bacteria are usually gram-negative, but gram-positive bacteria and anaerobes are also implicated in cholangitis.
Piperacillin/tazobactam and imipenem/cilastatin are reasonable initial choices.
Cefuroxime plus metronidazole is another option.
Metronidazole in combination with ciprofloxacin or levofloxacin or gentamicin are alternative regimens for penicillin-allergic patients. Fluoroquinolones can cause serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[44] The US Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[45][46]
Once biliary drainage has been achieved and the patient shows clinical improvement, consider switching to oral antibiotics for the remainder of the antibiotic course.
Medical management requires attention to several critical factors and assessment of disease severity.[29][42] For severe acute cholangitis, swift and appropriate respiratory and circulatory management is essential.[29]
Cholangitis can quickly become an acute, septic, life-threatening infection if not identified and treated promptly. Start treatment for sepsis immediately if a senior clinical decision-maker (e.g., ST4 level doctor in the UK) makes a diagnosis of suspected sepsis.[23][24][28] Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[27][28] See Sepsis in adults.
Patients with severe acute cholangitis often require bolused crystalloid 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, raised prothrombin time).
Use a strong opioid (e.g., morphine, oxycodone) in combination with paracetamol for pain management.
Biliary decompression and drainage are necessary to allow for clinical improvement.[29][40] 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 >39°C [>102°F], worsening confusional state)[29][30]
Within 24 to 72 hours after admission: those for whom antibiotic treatment and medical management provide stability can have the decompression procedure.[29][30][32][42]
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.[33][38][47][39]
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][41]
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.[30][33][40] Percutaneous trans-hepatic cholangiography (PTC) can be performed initially for those who are poor ERCP candidates (e.g., status post-Roux-en-Y gastric bypass, presence of oesophageal stricture) or for those who do not obtain relief of bile duct obstruction from ERCP.[33][40]
Both ERCP and PTC can be utilised for the purposes of common bile duct stone extraction and stent placement.
Endoscopic stent insertion by ERCP with decompression by aspiration is an option for patients too unwell to undergo either ERCP with sphincterotomy or PTC, 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.[40] While effective, nasobiliary drain placement is rarely performed in practice as these patients can usually undergo endoscopic stenting.
Historically, all patients with cholangitis were admitted to 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]
Non-operative procedures have largely replaced emergency surgery for accomplishing biliary decompression, owing to their superior risk-benefit ratio.[40]
If adequate biliary decompression/drainage is not accomplished via non-operative means, laparoscopic choledochotomy with T-tube placement or cholecystectomy with common bile duct exploration may need to be undertaken.[40] 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 stabilised patients carries a much lower risk of morbidity and mortality compared with emergency surgery.
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 endoscopic retrograde cholangiopancreatography (ERCP).
If primary sclerosing cholangitis (PSC) is present, it will almost always be identified on cholangiogram (obtained via ERCP or percutaneous trans-hepatic cholangiography [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. The long-term endoscopic management of PSC is complex and individualised, but often includes frequent ERCPs with tissue sampling to rule out cholangiocarcinoma and the use of balloon dilations and stents to manage symptomatic obstructing bile duct strictures.[49] 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.
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