Cholangitis in Emergency Medicine Follow-up

  • Author: Adam J Rosh, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 26, 2012
 

Further Inpatient Care

  • Admission to ICU for ill patients is appropriate.
  • Continue intravenous antibiotics.
    • Monitor the blood cultures so that the antibiotics can be narrowed to the appropriate pathogen.
    • Administer intravenous antibiotics 12-24 hours prior to nonemergent ERCP.
  • Refer worsening patients to emergent ERCP for sphincterotomy or percutaneous drainage.
  • Traditionally, antibiotics were administered for 7-10 days to treat cholangitis. However, it now appears that a 3-day course may be sufficient in patients who undergo adequate biliary drainage.
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Transfer

  • Transfer is appropriate in hospitals unable to manage significantly ill patients with intensive medical care, surgery, and endoscopic consultation.
  • Optimize patient stabilization prior to transfer.
  • Minimum initial stabilization includes the following:
    • Appropriate diagnostics
    • ABCs (including volume resuscitation)
    • Administration of broad-spectrum antibiotics
    • Critical care transport
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Deterrence/Prevention

  • Prophylactic antibiotics prior to ERCP may decrease risk of cholangitis.
  • Prompt recognition and treatment of symptomatic cholelithiasis in patients at higher risk for complications (eg, those with diabetes) decrease risk of cholangitis.
  • Aggressive search for CBD stones during diagnosis and treatment of cholecystitis may be necessary to prevent cholangitis.
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Complications

  • Patients are increasingly likely to have complications with greater degrees of illness, as follows:
    • Liver failure, hepatic abscesses, and microabscesses
    • Bacteremia (25-40%); gram-negative sepsis
    • Acute renal failure
    • Catheter-related problems in patients treated with percutaneous or endoscopic drainage
      • Bleeding (intra-abdominally or percutaneously)
      • Catheter-related sepsis
      • Fistulae
      • Bile leak (intraperitoneally or percutaneously)
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Prognosis

  • Prognosis depends on several factors.[10]
    • Early recognition and treatment of cholangitis
    • Response to therapy
    • Underlying medical conditions of the patient
  • Mortality rate ranges from 5-10%, with a higher mortality rate in patients who require emergency decompression or surgery.
  • In patients responding to antibiotic therapy, the prognosis is good.
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Contributor Information and Disclosures
Author

Adam J Rosh, MD  Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey A Manko, MD  Assistant Professor of Emergency Medicine, Director, Emergency Medicine Residency Program, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center

Jeffrey A Manko, MD is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sally Santen, MD  Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  23. Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin North Am. Dec 2003;32(4):1145-68. [Medline].

 
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Sonogram of dilated intrahepatic ducts.
CT scan of common bile duct occluded by stone. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of 1-cm dilated common bile duct at portal triad. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of dilated intrahepatic bile ducts. Image courtesy of David Schwartz, MD, New York University Hospital.
Algorithm for management of patients with acute cholangitis.
 
 
 
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