Treatment

Empiric antibiotic therapy and urgent biliary drainage are the mainstays of treatment of acute cholangitis. The choice and timing of both biliary drainage and any procedure to treat the underlying cause are dictated by the severity of the disease at presentation

• Stabilize the patient as needed.

• Administer empiric antibiotic therapy for acute biliary infection to all patients.

• Determine the need and timing for urgent biliary drainage and treatment of the underlying cause, based on severity grading for acute cholangitis.

• Identify and treat concurrent choledocholithiasis.Provide initial supportive therapy for acute biliary disease

Initiate supportive therapy and broad-spectrum antibiotics as early as possible!

• Antibiotic therapy alone may be sufficient.

• Consider urgent biliary drainage within 24–48 hours of presentation in patients with either of the following:

  • No response to antibiotic therapy within 24 hours

  • Choledocholithiasis

• Underlying cause

  • If antibiotics are given alone: Treat electively, after acute symptoms resolve.

  • If biliary drainage is performed: Treat concurrently (i.e., a single-stage procedure).

• Urgent biliary drainage within 24–48 hours of presentation

• Underlying cause

  • Treat concurrently with biliary drainage (i.e., a single-stage procedure)

  • OR treat electively, after the patient improves with biliary drainage (i.e., a two-stage procedure)

• Urgent biliary drainage within 24 hours of presentation

• Treat the underlying cause once the patient's condition improves after urgent biliary drainage (i.e., a two-stage procedure)

Urgent drainage of infected bile is imperative in order to achieve rapid source control in patients with grade II–III acute cholangitis.

• Therapeutic ERCP-guided transpapillary biliary drainage

  • Indication: preferred biliary drainage procedure in acute cholangitis

  • Procedures

    • ERCP with papillotomy (sphincterotomy)

    • ERCP with temporary biliary stenting

• Indications

  • Second-line procedure if ERCP-guided drainage is unsuccessful

  • Second-line procedure if balloon-enteroscopy-assisted ERCP is not feasible in patients with altered upper gastrointestinal anatomy

• Procedure: Under EUS guidance, a fistula is created and a stent placed between the stomach/duodenum and the CBD/(dilated) hepatic duct to allow for internal biliary drainage.

• Double balloon enteroscopy-assisted ERCP

• Percutaneous transhepatic biliary drainage (PTBD)

• Surgical choledochotomy with T-tube biliary drainage

Bile obtained during the biliary drainage procedure should be sent for culture and sensitivity, and antibiotic therapy tailored accordingly.

• For choledocholithiasis [2]

  • ERCP-guided stone extraction

  • Elective interval cholecystectomy: ∼ 6 weeks after the resolution of acute symptoms to minimize the risk of recurrence

• For biliary stricture: ERCP and CBD stenting

• For parasitic infections (rare): ERCP-guided parasite extraction and anthelmintics

• Sepsis, septic shock, MODS (Multiple organ dysfunction syndrome)

  
  

  —> Increased intraductal pressures within the biliary tree → bacterial translocation from bile into the systemic circulation → bacteremia → sepsis, septic shock, and MODS if untreated.

• Pyogenic liver abscess

• Pericholecystic abscess

• Biliary stricture