Cholangitis Treatment & Management

Updated: Mar 11, 2020
  • Author: Homayoun Shojamanesh, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Treatment

Medical Care

Administration of broad-spectrum intravenous antibiotics and correction of fluid and electrolyte imbalances constitute essential medical care for cholangitis. [11, 12] Patients should take nothing by mouth in the acute stage of cholangitis. Accomplish hydration with intravenous fluids.

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

Note the following:

  • 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. [13]

  • For patients with severe cholangitis, endoscopic biliary drainage (using a stent or endoscopic nasobiliary drain [ENBD]) has replaced emergency surgical common duct exploration and T-tube drainage as standard treatment. Data from a metaanalysis indicate that ENBD may cause fewer perioperative complications (eg, preoperative cholangitis rate, postoperative pancreatic fistula rate) than endoscopic biliary stenting (EBS) in patients with malignant biliary obstruction. [14] However, a limitation of the metaanalysis was that there were no data from randomized controlled trials.

  • Endoscopic biliary drainage is relatively easy in the presence of common bile duct (CBD) stones, a lower CBD block (eg, pancreatic or periampullary cancer), and choledochal cyst. This procedure may be difficult in patients with a high block (eg, hilar cholangiocarcinoma or gall bladder cancer). In these patients, the primary (and, sometimes, even the secondary) biliary ductal confluence may be blocked, and bilateral (or even multiple) drainage is required to control cholangitis. This may be difficult or even impossible to achieve endoscopically, and percutaneous transhepatic biliary drainage may be required.

  • Percutaneous transhepatic biliary drainage (PTBD) is another possible nonsurgical method of biliary drainage. PTBD is required in patients with high block when endoscopic biliary drainage may not be possible. Bilateral (even multiple) tubes may have to be placed.

Consultations

Obtain consultations with the following specialists in a timely manner:

  • Radiologists

  • Gastroenterologists

  • Surgeons

Prevention

Consider maintenance therapy/antibiotics (ie, sulfamethoxazole and trimethoprim [SMZ-TMP] or a fluoroquinolone) for patients with recurrent cholangitis.

It has been reported that prophylactic antibiotics do not prevent endoscopic retrograde cholangiopancreatography (ERCP)-induced cholangitis significantly in unselected patients, and these agents should not be routinely recommended for this reason. [15]

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Surgical Care

Endoscopic or percutaneous biliary drainage and decompression have usually replaced surgery as the initial treatment of severe cholangitis. Surgical decompression in the form of T-tube drainage of the common bile duct (CBD) (choledochostomy) is appropriate for patients in whom endoscopic or transhepatic drainage is unsuccessful or unavailable. This can be performed laparoscopically also.

Following adequate biliary drainage and decompression for acute cholangitis with bacteremia, Park et al found no significant differences in the recurrence of acute cholangitis and 30-day mortality between early switch to oral antibiotic therapy and standard 10-day intravenous antibiotic therapy. [16]

Definitive management depends on the underlying cause (eg, removal of CBD stones, resection of tumor, excision of choledochal cyst, percutaneous balloon dilatation, and stenting of anastomotic stricture). Cholangitis, however, must be controlled before the patient undergoes operative intervention. In the case of an unresectable cancer, definitive palliation can be achieved with placement of self-expandable metal stents (SEMS) which remain patent over a long period (eg, plastic stents).

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