eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholangitis: Follow-up

Author: Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Coauthor(s): Jeffrey A Manko, MD, Assistant Professor of Clinical Surgery/Emergency Medicine, Director, Emergency Medicine Residency Program, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center; Sally Santen, MD, Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University
Contributor Information and Disclosures

Updated: Sep 29, 2009

Follow-up

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.

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

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.

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)

Prognosis

  • Prognosis depends on several factors.8
    • 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.

Miscellaneous

Special Concerns

  • Because pregnant women are prone to symptomatic gallstones, consider cholangitis in pregnant, febrile, or jaundiced patients. Differentiate cholangitis from HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) of preeclampsia, which also can cause abdominal pain and elevated LFTs. Blood pressure is elevated in preeclampsia and may be hypotensive in cholangitis.
  • Cholelithiasis and cholangitis are uncommon in children, except in those with underlying hemolytic disorders or biliary anomalies.
  • The incidence of cholangitis is higher in elderly persons, most likely due to the increased prevalence of common bile duct stones with age. As in other infections and abdominal processes, elderly patients frequently do not manifest pathology in a classic pattern. Consider cholangitis in febrile or hypotensive elderly patients.
 


More on Cholangitis

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

  1. Aron JH, Bowlus CL. The immunobiology of primary sclerosing cholangitis. Semin Immunopathol. May 26 2009;[Medline].

  2. Kashyap R, Mantry P, Sharma R, Maloo MK, Safadjou S, Qi Y, et al. Comparative Analysis of Outcomes in Living and Deceased Donor Liver Transplants for Primary Sclerosing Cholangitis. J Gastrointest Surg. May 9 2009;[Medline].

  3. 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].

  4. Kinney TP. Management of ascending cholangitis. Gastrointest Endosc Clin N Am. Apr 2007;17(2):289-306, vi. [Medline].

  5. Jabara B, Fargen KM, Beech S, Slakey DR. Diagnosis of cholangiocarcinoma: a case series and literature review. J La State Med Soc. Mar-Apr 2009;161(2):89-94. [Medline].

  6. Rustemovic N, Cukovic-Cavka S, Opacic M, Petrovecki M, Hrstic I, Radic D, et al. Endoscopic ultrasound elastography as a method for screening the patients with suspected primary sclerosing cholangitis. Eur J Gastroenterol Hepatol. Jun 2 2009;[Medline].

  7. Itoi T, Kawai T, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, 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. Jul 2008;68(1):84-90. [Medline].

  8. Rosing DK, De Virgilio C, Nguyen AT, et al. Cholangitis: analysis of admission prognostic indicators and outcomes. Am Surg. Oct 2007;73(10):949-54. [Medline].

  9. Bornman PC, van Beljon JI, Krige JE. Management of cholangitis. J Hepatobiliary Pancreat Surg. 2003;10(6):406-14. [Medline].

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

  11. Jain MK, Jain R. Acute bacterial cholangitis. Curr Treat Options Gastroenterol. Apr 2006;9(2):113-21. [Medline].

  12. Lai EC. Management of severe acute cholangitis. Br J Surg. Jun 1990;77(6):604-5. [Medline].

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

  14. Muir CA. Acute ascending cholangitis. Clin J Oncol Nurs. Apr 2004;8(2):157-60. [Medline].

  15. Qureshi WA. Approach to the patient who has suspected acute bacterial cholangitis. Gastroenterol Clin North Am. Jun 2006;35(2):409-23. [Medline].

  16. Romagnuolo J, Bardou M, Rahme E, et al. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med. Oct 7 2003;139(7):547-57.

  17. Sievert W, Vakil NB. Emergencies of the biliary tract. Gastroenterol Clin North Am. Jun 1988;17(2):245-64. [Medline].

  18. Sinanan MN. Acute cholangitis. Infect Dis Clin North Am. Sep 1992;6(3):571-99. [Medline].

  19. 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].

  20. 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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Further Reading

Clinical guidelines

ACR Appropriateness Criteria® right upper quadrant pain.
American College of Radiology - Medical Specialty Society.  1996 (revised 2005).  5 pages.  [NGC Update Pending] NGC:004781

AASLD practice guidelines: evaluation of the patient for liver transplantation.
American Association for the Study of Liver Diseases - Private Nonprofit Research Organization.  2000 Jan (revised 2005 Jun).  26 pages.  NGC:004333


Clinical trials

Compare Conventional Colonosocpy to Endoscopic AFI, NBI for Dysplasia Detection for Ulcerative Colitis & Cholangitis

Probiotics in Patients With Primary Sclerosing Cholangitis

Differential Gene Expression of Liver Tissue and Blood From Individuals With Chronic Viral Hepatitis

Related eMedicine topics

Cholangitis (Emergency Medicine) Cholangitis, Primary Sclerosing (Radiology)

Primary Sclerosing Cholangitis (Gastroenterology)

Primary Sclerosing Cholangitis (Pediatrics: General Medicine)

Recurrent Pyogenic Cholangitis (Gastroenterology)

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Keywords

cholangitis, gallstone, gall stone, gallbladder, biliary tract obstruction, common bile duct obstruction, primary sclerosing cholangitis, cholecystitis, biliary colic, cholelithiasis, cholangitis treatment, cholangitis symptoms, CBD, CBD stones

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Contributor Information and Disclosures

Author

Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Adam J Rosh, MD, MS 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 Clinical Surgery/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.

Medical Editor

David FM Brown, MD, Assistant 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.

Pharmacy Editor

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

Managing Editor

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.

CME Editor

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, Emergency Medicine, University Hospitals, Case Medical Center
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.

 
 
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