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:
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Immediate assessment of ABCs (airway, breathing, circulation)
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Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
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Stabilization (eg, oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable patients)
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Rapid transport
Emergency Department Care
Suspect mild cholangitis in patients with jaundice and a fever; consider cholangitis in all patients with sepsis.
The degree of urgency of treatment depends on severity of illness. Important points are resuscitation, diagnosis, and treatment.
Management of acute cholangitis in the emergency department includes the following:
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After assessment of the ABCs (airway, breathing, circulation), place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an electrocardiogram (ECG). Draw and send laboratory studies (including blood cultures) when the intravenous line is placed.
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Provide fluid resuscitation with intravenous (IV) crystalloid solution (eg, 0.9% normal saline).
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Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
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Correct any electrolyte abnormalities or coagulopathies.
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For management of patients in septic shock, see Shock, Septic.
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Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree. [17]
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A nasogastric tube may be helpful for patients who are vomiting.
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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. [5] 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%.
Zhang et al indicate that endoscopic sphincterotomy is safe and effective for temporary biliary decompression in patients with acute obstructive cholangitis, and endoscopic nasobiliary drainage without sphincterotomy may be considered as a first-line therapy in this setting. [18] The investigators also suggested that endoscopic sphincterotomy may improve the effectiveness of endoscopic nasobiliary drainage in those with papillary inflammation stricture and thick bile.
Medical therapy can be complementary to surgical or endoscopic treatments. In less ill patients, medical treatment may be all that is necessary. Perform the following:
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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 endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, or percutaneous drainage. [14] See the management algorithm below.
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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. [19]
Endoscopic nasobiliary drainage (ENBD) is a technique that is being used in Asia in the surgical management of acute cholangitis. [20] Data from a meta-analysis 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. [21] However, a limitation of the meta-analysis was that there were no data from randomized controlled trials.
Medical Care
Admission to the intensive care unit (ICU) for ill patients is appropriate. Continue intravenous antibiotics; monitor the blood cultures so that the antibiotics can be narrowed to the appropriate pathogen, and provide supportive measures including administration of intravenous fluids. [17] Administer intravenous antibiotics 12-24 hours prior to nonemergent endoscopic retrograde cholangiopancreatography (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. [22]
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:
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Appropriate diagnostics
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ABCs (including volume resuscitation)
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Administration of broad-spectrum antibiotics
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Critical care transport
Consultations
Immediately consult a surgeon and a gastroenterologist.
Although 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.
Prevention
Prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography (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 commond bile duct stones during diagnosis and treatment of cholecystitis may be necessary to prevent cholangitis.
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Sonogram of dilated intrahepatic ducts.
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CT scan of common bile duct occluded by stone. Image courtesy of David Schwartz, MD, New York University Hospital.
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CT scan of 1-cm dilated common bile duct at portal triad. Image courtesy of David Schwartz, MD, New York University Hospital.
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CT scan of dilated intrahepatic bile ducts. Image courtesy of David Schwartz, MD, New York University Hospital.
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Algorithm for management of patients with acute cholangitis.
