Overview
Cholangitis is a life-threatening infection of the biliary tract, often requiring urgent intervention to prevent high mortality rates 12.Diagnosis
Key Diagnostic Criteria: Presence of Charcot's triad (fever, jaundice, right upper quadrant pain) or Reynold's pentad (Charcot's triad plus altered mental status, hypotension, and respiratory failure) 2.
Recommended Tests: Laboratory tests showing elevated liver enzymes, leukocytosis, and imaging studies (e.g., MRCP, ERCP) to identify biliary obstruction and stones 12.
Scoring Systems: Use scoring systems like the Tokyo-Kyoto criteria to assess severity and guide timing of intervention 2.Management
First-Line Treatments:
- Antibiotics: Broad-spectrum antibiotics (e.g., third-generation cephalosporins) initiated promptly 12.
- Fluid Resuscitation: Aggressive fluid therapy to correct hemodynamic instability 12.
Intervention:
- Endoscopic Drainage: Preferred over percutaneous drainage; biliary decompression within 48 hours 1.
- Sphincterotomy and Stone Removal: Recommended when feasible, combined with drainage to prevent recurrence 1.
Adjunctive Treatments:
- Plasmapheresis: Considered in cases with multiorgan failure and disseminated intravascular coagulation (DIC) 8.
- Haemodialysis: May be necessary for renal failure complicating cholangitis 8.Special Populations
Elderly: Management similar to general population but with careful consideration of comorbidities and frailty 1.
Comorbidities: Pre-existing renal dysfunction and presence of extended-spectrum beta-lactamase (ESBL) organisms increase risk of organ failure 4.Key Recommendations
Endoscopic Drainage Preferred: Use endoscopic rather than percutaneous drainage for biliary decompression 1 (Evidence: Strong).
Timing of Intervention: Perform biliary decompression within 48 hours of diagnosis 1 (Evidence: Strong).
Comprehensive Therapy: Combine sphincterotomy and stone removal with drainage unless patient instability precludes it 1 (Evidence: Strong).
Risk Assessment: Utilize scoring systems like the Tokyo-Kyoto criteria to guide management decisions 2 (Evidence: Moderate).
Antibiotic Therapy: Initiate broad-spectrum antibiotics early in the course of treatment 12 (Evidence: Strong).References
1 Buxbaum JL, Buitrago C, Lee A, Elmunzer BJ, Riaz A, Ceppa EP et al.. ASGE guideline on the management of cholangitis. Gastrointestinal endoscopy 2021. link
2 Ely R, Long B, Koyfman A. The Emergency Medicine-Focused Review of Cholangitis. The Journal of emergency medicine 2018. link
3 Peixoto A, Silva M, Macedo G. Cholangitis after endoscopic retrograde cholangiopancreatography: a rare complication?. Revista espanola de enfermedades digestivas 2017. link
4 Lee JM, Lee SH, Chung KH, Park JM, Lee BS, Paik WH et al.. Risk factors of organ failure in cholangitis with bacteriobilia. World journal of gastroenterology 2015. link
5 Wilson MK, Stephen MS, Mathur M, Sheldon D, Storey D. Recurrent pyogenic cholangitis or "oriental cholangiohepatitis' in occidentals: case reports of four patients. The Australian and New Zealand journal of surgery 1996. link
6 Matthews JB, Baer HU, Schweizer WP, Gertsch P, Carrel T, Blumgart LH. Recurrent cholangitis with and without anastomotic stricture after biliary-enteric bypass. Archives of surgery (Chicago, Ill. : 1960) 1993. link
7 Choi BI, Han JK, Park YH, Yoon YB, Han MC, Kim CW. Retained intrahepatic stones: treatment with piezoelectric lithotripsy combined with stone extraction. Radiology 1991. link
8 Ahrén B, Evander A, Hammarström LE, Simonsen O. Plasmapheresis and haemodialysis in a case of septic cholangitis complicated by hepatic and renal failure. Case report. Acta chirurgica Scandinavica 1988. link
9 Hymes JL, Haicken BN, Schein CJ. Varices of the common bile duct as a surgical hazard. The American surgeon 1977. link