eMedicine Specialties > Gastroenterology > Biliary

Cholangitis: Treatment & Medication

Author: Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Coauthor(s): Praveen K Roy, MD,, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute, Albuquerque; Victor Nwakakwa, MD, MRCP (UK), Clinical Instructor, Department of Internal Medicine, Division of Gastroenterology, University of Virginia Health System
Contributor Information and Disclosures

Updated: Nov 16, 2009

Treatment

Medical Care

Administration of broad-spectrum intravenous antibiotics and correction of fluid and electrolyte imbalances constitute essential medical care for cholangitis.

  • High biliary pressures caused by an obstruction may impair the biliary secretion of antibiotics; therefore, treatment may require decompression and drainage of the biliary system.
  • For patients with severe cholangitis, endoscopic drainage has replaced emergency surgical common duct exploration and T-tube drainage as standard treatment.
  • Percutaneous transhepatic biliary drainage (PTBD) is another possible nonsurgical method of biliary drainage.

Surgical Care

Endoscopic biliary drainage and decompression have usually replaced surgery as the initial treatment of severe cholangitis. Surgical decompression is appropriate for patients in whom endoscopic or transhepatic drainage is unsuccessful or unavailable.

Consultations

  • Gastroenterologists
  • Surgeons
  • Radiologists

Diet

Patients should take nothing by mouth in the acute stage of cholangitis. Accomplish hydration with intravenous fluids.

Medication

Possible antibiotic treatments include penicillin derivatives (eg, piperacillin) or a second- or third-generation cephalosporin (eg, ceftazidime) for gram-negative coverage, ampicillin for gram-positive coverage, and metronidazole for anaerobic coverage. Some researchers have reported use of fluoroquinolones (eg, ciprofloxacin, levofloxacin) as effective therapy.

The selection and dosing of appropriate antibiotics and other medications listed below or from another source must be performed by the patient's primary physician and gastroenterologist based on history and clinical presentation.

Antibiotics

Initial empiric antimicrobial therapy must be comprehensive and should cover both aerobic and anaerobic gram-negative organisms.


Piperacillin (Pipracil)

Inhibits biosynthesis of cell wall mucopeptides and the stage of active multiplication; has antipseudomonal activity.

Adult

2-3 g/dose IV/IM q6-12h; not to exceed 2 g with IM injection
Serious infection: 3-4 g/dose IV/IM q4-6h; not to exceed 24 g/d

Pediatric

200-300 mg/kg/d IV/IM divided q4-6h

Tetracyclines may decrease effects; high concentrations may physically inactivate aminoglycosides; probenecid may increase levels; coadministration with aminoglycosides has synergistic effects

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in renal impairment and in history of seizures


Ceftazidime (Ceptaz, Fortaz, Tazidime)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Adult

250 mg to 2 g IV/IM q8-12h

Pediatric

Neonates: 30 mg/kg IV q12h
Infants and children: 30-50 mg/kg/dose IV q8h; not to exceed 6 g/d
Adolescents: Administer as in adults

Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase levels

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

Bactericidal activity against susceptible organisms.

Adult

250-500 mg PO q6h
500 mg to 1.5 g IM q4-6h
500 mg to 3 g IV q4-6h; not to exceed 12 g/d

Pediatric

50-100 mg/kg/d PO divided q4-6h
100-400 mg/kg/d IV/IM divided q4-6h

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal failure; evaluate rash, and differentiate from hypersensitivity reaction


Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa.

Adult

Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg or 500 mg IV for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d

Pediatric

Administer as in adults using body weight

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Ciprofloxacin (Cipro)

Fluoroquinolone with activity against Pseudomonas species, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

250-500 mg PO bid for 7-14 d
Alternatively, 200-400 mg IV q12h

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.

Adult

500 mg PO/IV qd for 7-14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Coagulants

Vitamin K or fresh frozen plasma (FFP) may be used for correction of coagulopathy when needed.


Phytonadione (AquaMEPHYTON, Konakion, Mephyton)

Promotes liver synthesis of clotting factors that in turn inhibit warfarin effects.

Adult

5-25 mg/d PO; alternatively, 10 mg IV/IM/SC

Pediatric

2.5-5 mg/d PO; alternatively, 1-2 mg/dose as single dose

Effects of warfarin sodium and dicumarol are antagonized by phytonadione

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Ineffective in hereditary hypoprothrombinemia


Fresh frozen plasma (FFP)

Plasma is the fluid compartment of blood containing the soluble clotting factors. Indications for using FFP include bleeding in patients with congenital coagulation defects and multiple coagulation factor deficiencies (severe liver disease).

Adult

IV as directed by protocol

Pediatric

Administer as in adults

Pregnancy

A - Safe in pregnancy

Precautions

Viral contamination and infection are possible but unlikely because of prescreening; ineffective in patients with factor IX inhibitors; may induce an anamnestic response

More on Cholangitis

Overview: Cholangitis
Differential Diagnoses & Workup: Cholangitis
Treatment & Medication: Cholangitis
Follow-up: Cholangitis
References
Further Reading
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References

  1. Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. Aug 4 2009;[Medline].

  2. Lee KF, Chong CN, Ng D, et al. Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study. HPB (Oxford). 2009;11(1):75-80. [Medline]. [Full Text].

  3. Shojaiefard A, Esmaeilzadeh M, Ghafouri A, Mehrabi A. Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract. 2009;2009:840208. [Medline].

  4. Li FY, Cheng NS, Mao H, Jiang LS, et al. Significance of controlling chronic proliferative cholangitis in the treatment of hepatolithiasis. World J Surg. Jul 30 2009;epub ahead of print. [Medline].

  5. Bai Y, Gao F, Gao J, Zou DW, Li ZS. Prophylactic antibiotics cannot prevent endoscopic retrograde cholangiopancreatography-induced cholangitis: a meta-analysis. Pancreas. Mar 2009;38(2):126-30. [Medline].

  6. Bilhartz LE, Horton JD. Gallstone disease and its complications. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. 1998:948-972.

  7. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. Sep 2000;14(3):521-46. [Medline].

  8. Kadakia SC. Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis. Med Clin North Am. Sep 1993;77(5):1015-36. [Medline].

  9. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. Jun 11 1992;326(24):1582-6. [Medline].

  10. Lameris JS, Overhagen HV. Imaging and intervention in patients with acute right upper quadrant disease. In: Bailliere's Clinical Gastroenterology. Vol 9. Harcourt Brace & Co;1995:21-36.

  11. Lee DW, Chung SC. Biliary infection. In: Bailliere's Clinical Gastroenterology. Vol 11. Harcourt Brace & Co;1997:707-724.

  12. Leung JW, Yu AS. Hepatolithiasis and biliary parasites. Bailliere's Clinical Gastroenterology. 1997;11:681-706.

  13. Lillemoe KD. Surgical treatment of biliary tract infections. Am Surg. Feb 2000;66(2):138-44. [Medline].

  14. Lipsett PA, Pitt HA. Acute cholangitis. Surg Clin North Am. Dec 1990;70(6):1297-312. [Medline].

  15. Raraty MG, Finch M, Neoptolemos JP. Acute cholangitis and pancreatitis secondary to common duct stones: management update. World J Surg. Nov 1998;22(11):1155-61. [Medline].

  16. van den Hazel SJ, Speelman P, Tytgat GN, et al. Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis. Clin Infect Dis. Aug 1994;19(2):279-86. [Medline].

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Keywords

cholangitis, acute cholangitis, ascending cholangitis, choledocholithiasis, biliary tract obstruction, angiocholitis, cholangeitis, hepatolithiasis, sump syndrome, pyogenic liver abscess, acute renal failure, liver disease, Escherichia coli, E coli, Klebsiella species, Enterococcus species, Bacteroides fragilis, B fragilis

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Contributor Information and Disclosures

Author

Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Homayoun Shojamanesh, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Praveen K Roy, MD,, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute, Albuquerque
Praveen K Roy, MD, is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Victor Nwakakwa, MD, MRCP (UK), Clinical Instructor, Department of Internal Medicine, Division of Gastroenterology, University of Virginia Health System
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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