Acute Cholangitis

Acute cholangitis is bacterial infection of an obstructed biliary system.

Common causes are choledocholithiasis, malignant biliary obstruction, benign biliary stricture and blocked biliary stents.

The combination of obstruction and infection raises intraductal pressure, promoting bacteraemia and rapid progression to septic shock.

Antibiotics alone are inadequate when significant obstruction persists. Definitive treatment requires biliary decompression.

Charcot triad:

• Right upper quadrant pain
• Fever
• Jaundice

Severe disease may produce hypotension and altered mental status, completing Reynolds pentad.

Do not require the complete triad before diagnosing cholangitis. Older or immunosuppressed patients may have minimal pain or fever.

Organ dysfunction, rising lactate, oliguria or vasopressor requirement indicates severe disease.

Check full blood count, renal function, liver profile, coagulation and lactate.

Obtain blood cultures before antibiotics where this does not delay treatment.

Ultrasound: establish biliary dilatation and a likely level of obstruction.

MRCP is useful in a stable uncertain case but should not delay decompression when sepsis and obstruction are already established.

Begin sepsis resuscitation immediately.

A practical community acquired regimen is:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, with renal adjustment.

An alternative in a stable lower risk patient is:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

Adjust treatment to blood and bile cultures.

Biliary decompression

ERCP is preferred for biliary drainage.

Perform drainage within 48 hours, and substantially earlier in septic shock or progressive organ dysfunction.

In a stable patient, ERCP can combine decompression with sphincterotomy and complete stone extraction.

In a severely unstable patient, prioritise rapid decompression with a stent or nasobiliary drain rather than prolonging the procedure for difficult stone clearance.

When ERCP is impossible or unsuccessful, use percutaneous transhepatic biliary drainage. Therapeutic endoscopic ultrasound guided drainage is another option in centres with appropriate expertise.

Once source control is achieved and the patient improves, antimicrobial treatment is usually continued for approximately 4 to 7 days, modified by bacteraemia, organism and clinical course.

For gallstone related cholangitis, perform definitive cholecystectomy after duct clearance and physiological recovery, preferably during the same admission where feasible.