Acute Cholangitis Follow-up
- Author: Timothy M Scott, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
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.
In addition, a study by Park et al indicated that in patients with acute cholangitis with bacteremia who have achieved successful biliary drainage, treatment with an early switch from intravenous to oral antibiotics is just as effective as conventional 10-day intravenous antibiotic therapy. The study involved 59 patients, including 30 who underwent conventional intravenous antibiotic treatment and 29 who were switched early in treatment to oral antibiotics. At follow-up, 30 days after diagnosis, the investigators determined that the bacterial eradication rate was not significantly different between the two groups, being 93.3% for the conventional treatment patients and 93.1% for the early switch group. Moreover, the groups showed no statistically significant differences in the recurrence rate for acute cholangitis and the 30-day mortality rate.
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:
ABCs (including volume resuscitation)
Administration of broad-spectrum antibiotics
Critical care transport
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.
Kashyap R, Mantry P, Sharma R, et al. Comparative analysis of outcomes in living and deceased donor liver transplants for primary sclerosing cholangitis. J Gastrointest Surg. 2009 Aug. 13(8):1480-6. [Medline].
van Erpecum KJ. Gallstone disease. Complications of bile-duct stones: Acute cholangitis and pancreatitis. Best Pract Res Clin Gastroenterol. 2006. 20(6):1139-52. [Medline].
Rosing DK, De Virgilio C, Nguyen AT, El Masry M, Kaji AH, Stabile BE. Cholangitis: analysis of admission prognostic indicators and outcomes. Am Surg. 2007 Oct. 73(10):949-54. [Medline].
Kinney TP. Management of ascending cholangitis. Gastrointest Endosc Clin N Am. 2007 Apr. 17(2):289-306, vi. [Medline].
Jabara B, Fargen KM, Beech S, Slakey DR. Diagnosis of cholangiocarcinoma: a case series and literature review. J La State Med Soc. 2009 Mar-Apr. 161(2):89-94. [Medline].
Shinya S, Sasaki T, Yamashita Y, et al. Procalcitonin as a useful biomarker for determining the need to perform emergency biliary drainage in cases of acute cholangitis. J Hepatobiliary Pancreat Sci. 2014 Oct. 21 (10):777-85. [Medline].
Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. 2008 Jul. 92(4):925-60, x. [Medline].
Rustemovic N, Cukovic-Cavka S, Opacic M, et al. Endoscopic ultrasound elastography as a method for screening the patients with suspected primary sclerosing cholangitis. Eur J Gastroenterol Hepatol. 2010 Jun. 22(6):748-53. [Medline].
Zhang RL, Zhao H, Dai YM, et al. Endoscopic nasobiliary drainage with sphincterotomy in acute obstructive cholangitis: a prospective randomized controlled trial. J Dig Dis. 2014 Feb. 15 (2):78-84. [Medline].
Sharma BC, Agarwal N, Sharma P, Sarin SK. Endoscopic biliary drainage by 7 Fr or 10 Fr stent placement in patients with acute cholangitis. Dig Dis Sci. 2009 Jun. 54(6):1355-9. [Medline].
Itoi T, Kawai T, Sofuni A, et al. Efficacy and safety of 1-step transnasal endoscopic nasobiliary drainage for the treatment of acute cholangitis in patients with previous endoscopic sphincterotomy (with videos). Gastrointest Endosc. 2008 Jul. 68(1):84-90. [Medline].
Park TY, Choi JS, Song TJ, et al. Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia. Dig Dis Sci. 2014 Nov. 59(11):2790-6. [Medline].
Tabibian JH, Yang JD, Baron TH, Kane SV, Enders FB, Gostout CJ. Weekend admission for acute cholangitis does not adversely impact clinical or endoscopic outcomes. Dig Dis Sci. 2015 Sep 21. [Medline].
Zimmer V, Lammert F. Acute bacterial cholangitis. Viszeralmedizin. 2015 Jun. 31 (3):166-72. [Medline].