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

Intravenous, broad-spectrum antibiotics are administered until blood and bile culture results are obtained. Treatment course is generally 4-7 days.[28]

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. 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.

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.

Start treatment 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.

Patients with severe acute cholangitis 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.

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]

Primary options

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

cefepime: 1-2 g intravenously every 12 hours

and

metronidazole: 500 mg intravenously every 8 hours

Secondary options

metronidazole: 500 mg intravenously every 8 hours

-- AND --

ciprofloxacin: 400 mg intravenously every 12 hours

levofloxacin: 500-750 mg intravenously every 24 hours

gentamicin: 3-5 mg/kg/day intravenously given in divided doses every 8 hours

and

metronidazole: 500 mg intravenously every 8 hours

Plus – biliary decompression: nonoperative

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Plus –

biliary decompression: nonoperative

Treatment recommended for ALL patients in selected patient group

Patients with a deteriorating status despite initial antibiotic treatment and intensive medical management require decompression interventions be undertaken in an emergent manner, within the first 12 hours following admission.[27][30] Signs of deterioration include: persistent abdominal pain, hypotension despite intravenous fluid administration, fever >102°F (39°C), or a worsening confusional state. For those patients responsive to initial treatment (i.e., not showing the signs of deterioration noted above), these interventions can be undertaken in a less urgent timeframe, within 24 to 72 hours after admission, lessening the risks of adverse consequences associated with the procedure.[27][30] 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]

Nonoperative procedures have largely replaced emergency surgery for accomplishing biliary decompression due to their superior risk-benefit ratio.[42]

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]

Observational studies and subsequent meta-analyses have shown that 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] 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).

Consider – lithotripsy

Consider – analgesia

2nd line – biliary decompression: surgical

Plus – intravenous antibiotics + ongoing medical management

Back

Plus –

intravenous antibiotics + ongoing medical management

Treatment recommended for ALL patients in selected patient group

Intravenous, broad-spectrum antibiotics are continued until blood and bile culture results are available and antibiotics can be tailored to the known pathogens. Treatment course is generally 4-7 days.[28]

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. Once the patient shows clinical improvement, consideration should be given to switching to oral antibiotics for the remainder of the antibiotic course.

Continue to monitor the patient for any signs of sepsis. For more detail on when to suspect sepsis and on its management, see Sepsis in adults.

Continue any medical management as required. This may include ongoing intravenous fluids (with monitoring for signs of fluid overload); intravenous potassium and/or magnesium as indicated by lab testing results; repletion of coagulation factors with fresh frozen plasma and platelets if coagulation parameters are abnormal; and oxygen therapy if indicated.

Primary options

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

cefepime: 1-2 g intravenously every 12 hours

and

metronidazole: 500 mg intravenously every 8 hours

Secondary options

metronidazole: 500 mg intravenously every 8 hours

-- AND --

ciprofloxacin: 400 mg intravenously every 12 hours

levofloxacin: 500-750 mg intravenously every 24 hours

gentamicin: 3-5 mg/kg/day intravenously given in divided doses every 8 hours

and

metronidazole: 500 mg intravenously every 8 hours

Consider – analgesia

ONGOING

with choledocholithiasis, PSC, or HIV cholangiopathy

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

Use of this content is subject to our disclaimer

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: nonoperative

lithotripsy

analgesia

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 + ongoing 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

analgesia

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: nonoperative

lithotripsy

analgesia

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 + ongoing 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

analgesia

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