Acute cholangitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acutely ill

1st line – intravenous antibiotics + intensive medical management

Back

1st line –

intravenous antibiotics + intensive medical management

Start intravenous, broad-spectrum antibiotics for all patients with suspected or confirmed cholangitis, with more specific treatment guided by results of blood and bile cultures.[32]

Bacteria are usually gram-negative, but gram-positive bacteria and anaerobes are also implicated in cholangitis. Options include piperacillin/tazobactam, and imipenem/cilastatin, cefuroxime plus metronidazole, or 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. 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.

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).

Monitor controlled oxygen therapy. An upper SpO₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.

Evidence suggests that liberal use of supplemental oxygen (target SpO₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[50]

A lower target SpO₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[51]

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours; or 1000 mg intravenously every 8 hours

cefuroxime: 750 mg intravenously every 6-8 hours, may increase to 1500 mg every 6-8 hours in severe infections

and

metronidazole: 500 mg intravenously every 8 hours

Secondary options

metronidazole: 500 mg intravenously every 8 hours

-- AND --

ciprofloxacin: 400 mg intravenously every 8-12 hours

levofloxacin: 500 mg intravenously every 12-24 hours

gentamicin: 5-7 mg/kg intravenously every 24 hours

Plus – biliary decompression: non-operative

Back

Plus –

biliary decompression: non-operative

Treatment recommended for ALL patients in selected patient group

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]

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]

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]

Consider – lithotripsy

Consider – opioid analgesic + paracetamol

Back

Consider –

opioid analgesic + paracetamol

Additional treatment recommended for SOME patients in selected patient group

Use a strong opioid (e.g., morphine, oxycodone) in combination with paracetamol for pain management.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially, adjust dose according to response, maximum 400 mg/day; 1-10 mg intravenously every 4 hours when required

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

-- AND --

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

2nd line – biliary decompression: surgical

Plus – intravenous antibiotics

Back

Plus –

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

Start iIntravenous, broad-spectrum antibiotics for all patients with suspected or confirmed cholangitis, with more specific treatment guided by results of blood and bile cultures.[32]

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

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours; or 1000 mg intravenously every 8 hours

cefuroxime: 750 mg intravenously every 6-8 hours, may increase to 1500 mg every 6-8 hours in severe infections

and

metronidazole: 500 mg intravenously every 8 hours

Secondary options

metronidazole: 500 mg intravenously every 8 hours

-- AND --

ciprofloxacin: 400 mg intravenously every 8-12 hours

levofloxacin: 500 mg intravenously every 12-24 hours

gentamicin: 5-7 mg/kg intravenously every 24 hours

Plus – intensive medical management

Back

Plus –

intensive medical management

Treatment recommended for ALL patients in selected patient group

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.

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).

Monitor controlled oxygen therapy. An upper SpO₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.

Evidence suggests that liberal use of supplemental oxygen (target SpO₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[50]

A lower target SpO₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[51]

Consider – opioid analgesic + paracetamol

Back

Consider –

opioid analgesic + paracetamol

Additional treatment recommended for SOME patients in selected patient group

Use a strong opioid (e.g., morphine, oxycodone) in combination with paracetamol for pain management.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially, adjust dose according to response, maximum 400 mg/day; 1-10 mg intravenously every 4 hours when required

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

-- AND --

ONGOING

with choledocholithiasis, PSC, or HIV cholangiopathy

1st line – referral for follow-up medical/surgical care

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Acute cholangitis

acutely ill

intravenous antibiotics + intensive medical management

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

biliary decompression: non-operative

lithotripsy

opioid analgesic + paracetamol

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

biliary decompression: surgical

intravenous antibiotics

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

intensive medical management

opioid analgesic + paracetamol

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

with choledocholithiasis, PSC, or HIV cholangiopathy

referral for follow-up medical/surgical care

Acute cholangitis

Treatment algorithm

acutely ill

intravenous antibiotics + intensive medical management

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

biliary decompression: non-operative

lithotripsy

opioid analgesic + paracetamol

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

biliary decompression: surgical

intravenous antibiotics

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

intensive medical management

opioid analgesic + paracetamol

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

with choledocholithiasis, PSC, or HIV cholangiopathy

referral for follow-up medical/surgical care