Cholangitis in Emergency Medicine Treatment & Management

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

Prehospital Care

  • Diagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice, and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line.
  • In unstable patients with cholangitis, prehospital care should include the following:
    • Immediate assessment of ABCs
    • Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
    • Stabilization (eg, oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable patients)
    • Rapid transport
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Emergency Department Care

  • Suspect mild cholangitis in patients with jaundice and a fever; consider cholangitis in all patients with sepsis.
  • Degree of urgency of treatment depends on severity of illness. Important points are resuscitation, diagnosis, and treatment.
  • After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG. Draw and send laboratory studies (including blood cultures) when the intravenous line is placed.
  • Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).
  • Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
  • Correct any electrolyte abnormalities or coagulopathies.
  • For management of patients in septic shock, see Shock, Septic.
  • Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree.
  • A nasogastric tube may be helpful for patients who are vomiting.
  • Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.
  • The surgical literature states that, in patients with mild cholangitis, 80-90% respond to medical therapy.[3] Approximately 15% do not respond and subsequently require immediate surgical or endoscopic decompression. Mortality rates approach 100% for patients who fail medical therapy and do not have surgical decompression.
  • In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness. In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
  • Medical therapy can be complementary to surgical or endoscopic treatments. In less ill patients, medical treatment may be all that is necessary.
  • Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below. Algorithm for management of patients with acute chAlgorithm for management of patients with acute cholangitis.
  • The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage. A study by Sharma showed equal safety and effectiveness when using a 7 Fr stent or 10 Fr stent for biliary drainage in patients with severe cholangitis.[8]
  • A novel technique that is being used in Asia in the surgical management of acute cholangitis is endoscopic nasobiliary drainage.[9]
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Consultations

  • Immediately consult a surgeon and a gastroenterologist.
  • While most patients respond to antibiotics and conservative care, a subset requires emergent procedures (eg, ERCP, percutaneous drainage). In deciding to drain, consult with a gastroenterologist and a surgeon.
  • Increased mortality is observed in patients with hypotension, acute renal failure, liver abscess, cirrhosis, high malignant strictures, female gender, and advanced age. Therefore, consider decompression earlier for these patients. Patients with malignant obstruction usually do not respond to antibiotics (59% compared to 85%).
  • Unstable septic patients require clinical judgment to determine if they will survive until medical therapy has a chance to work or if they require emergency decompression with its associated high mortality rate.
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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

  1. Aron JH, Bowlus CL. The immunobiology of primary sclerosing cholangitis. Semin Immunopathol. Sep 2009;31(3):383-97. [Medline]. [Full Text].

  2. 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. Aug 2009;13(8):1480-6. [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. Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. Jul 2008;92(4):925-60, x. [Medline].

  7. 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. Jun 2010;22(6):748-53. [Medline].

  8. 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. Jun 2009;54(6):1355-9. [Medline].

  9. 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. Jul 2008;68(1):84-90. [Medline].

  10. Rosing DK, De Virgilio C, Nguyen AT, El Masry M, Kaji AH, Stabile BE. Cholangitis: analysis of admission prognostic indicators and outcomes. Am Surg. Oct 2007;73(10):949-54. [Medline].

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

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

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

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

  15. Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. Sep 2009;6(9):533-41. [Medline].

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

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

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

  19. Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med. Oct 7 2003;139(7):547-57. [Medline].

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

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

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

  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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