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| ==Management==
| | {{familytree/start}} |
| | | {{familytree | | | | | | | | | F01 |- |-| -| F02 | -| F03 | | | | | | | F01=<div style="float: left; text-align: left; line-height: 150% ">''' Suspect symptomatic choledocholithiasis:''' |
| {{familytree/start |summary=Cholangitis}} | | ---- |
| {{familytree | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ RUQ abdominal pain <br> ❑ Intermittent fever &/or chills<br> ❑ Jaundice<br> ❑ Lethargy or confusion </div> }} | | ''' Symptomatic & uncomplicated choledocholithiasis:'''<br>❑ Acute or intermittent RUQ or epigastric pain, > 6 hours & associated w/ nausea & vomiting<br>❑ Elevated bilirubin , alkaline phosphatase and GGT levels</div>| F02=<div style="float: left; text-align: left; line-height: 150% ">''' Symptomatic & complicated choledocholithiasis:'''<br> |
| {{familytree | | | | | | | |!| | |}}
| | Features of symptomatic & uncomplicated choledocholithiasis w/ |
| {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; line-height: 150% ">''' Examine the patient:''' <BR>❑ Altered mental status<BR>❑ Febrile<BR>❑ Dehydrated<BR>❑ Jaundice<BR>❑ Hypotension<BR>❑ Tachycardia<BR>❑ Dyspnea<BR>❑ Hypoxemia<BR>❑ Abdominal tenderness</div>}} | | ---- |
| {{familytree | | | | | | | |!| | |}}
| | ''Acute cholangitis:''<br>❑ Fever, jaundice & leukocytosis |
| {{familytree | | | | | | | C01 | | C01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase</div>}}
| | ---- |
| {{familytree | | | | | | | |!| | |}}
| | ''Biliary pancreatitis:''<br>❑ Elevated amylase & lipase </div>|F03=Consider severity assessment & management for acute cholangitis & biliary pancreatitis accordingly}} |
| {{familytree | | | | | | | D01 | | D01=<div style="float: left; text-align: left; line-height: 150% ">''' [[Cholangitis resident survival guide#Diagnostic Criteria|Diagnostic criteria: ]]''' <ref name="Mayumi-2013">{{Cite journal | last1 = Mayumi | first1 = T. | last2 = Someya | first2 = K. | last3 = Ootubo | first3 = H. | last4 = Takama | first4 = T. | last5 = Kido | first5 = T. | last6 = Kamezaki | first6 = F. | last7 = Yoshida | first7 = M. | last8 = Takada | first8 = T. | title = Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. | journal = J UOEH | volume = 35 | issue = 4 | pages = 249-57 | month = Dec | year = 2013 | doi = | PMID = 24334691 }}</ref><br>❑ Systemic inflammation | |
| :❑ Fever >38℃ and/or shaking chills
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| :❑ WBC (×1000/μl) <4, or >10
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| :❑ CRP (mg/dl) ≥1<br>
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| ❑ Cholestasis
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| :❑ Jaundice with total bilirubin ≥2 (g/dl)
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| :❑ ALP (IU) >1.5×STD
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| :❑ GGT (IU) >1.5×STD
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| :❑ AST (IU) >1.5×STD
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| :❑ ALT (IU) >1.5×STD<br>
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| ❑ Imaging
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| :❑ Biliary dilatation
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| :❑ Evidence of etiology (stricture, stone, stent etc.)</div>}}
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| {{familytree | | | | | | | |!| | |}}
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| {{familytree | | | | | | | E01 | | |E01=<div style="float: left; text-align: left; line-height: 150% "><BR>❑ Hospital admission<BR>❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ Blood C&S<br>❑ Empiric IV antibiotics<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref>
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| :❑ Ceftriaxone 1 g IV every 24 hours + Metronidazole 500 mg IV every 8 hours
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| '''or''' | |
| :❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours<br>
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| ❑ Acute pain management
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| :❑ Ketorolac 30-60 mg IM/IV single dose | |
| '''or'''
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| :❑ Opioids until drainage or surgical intervention if ketorolac is contraindicated/pain not improving<br>
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| ❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]]<ref name="Mayumi-2013">{{Cite journal | last1 = Mayumi | first1 = T. | last2 = Someya | first2 = K. | last3 = Ootubo | first3 = H. | last4 = Takama | first4 = T. | last5 = Kido | first5 = T. | last6 = Kamezaki | first6 = F. | last7 = Yoshida | first7 = M. | last8 = Takada | first8 = T. | title = Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. | journal = J UOEH | volume = 35 | issue = 4 | pages = 249-57 | month = Dec | year = 2013 | doi = | PMID = 24334691 }}</ref></div>}} | |
| {{familytree | | | |,|-|-|-|+|-|-|-|.| |}}
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| {{familytree | | | F01 | | F02 | | F03 | | |F01=Grade 1 (Mild)|F02= Grade 2 (Moderate)|F03= Grade 3 (Severe)}}
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| {{familytree | | | |!| | | |!| | | |!| | |}}
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| {{familytree | | | G01 | | G02 | | G03 | | G01=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]]
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| :❑ Within 24 hours after diagnosis (every 6-12 hours)
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| :❑ During the time zone of 24-48 hours (every 6-12 hours)</div>|G02=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]]
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| :❑ Within 24 hours after diagnosis (every 6-12 hours)
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| :❑ During the time zone of 24-48 hours (every 6-12 hours)<br>❑ Immediate biliary tract drainage within 24-48 hours</div>|G03=<div style="float: left; text-align: left; line-height: 150% ">❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ IV antibiotics (full dose)<br>❑ IV pain management w/ analgesics<br>❑ [[Cholangitis resident survival guide#Severity Assessment Criteria|Assess severity]]
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| :❑ Within 24 hours after diagnosis (every 6-12 hours)
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| :❑ During the time zone of 24-48 hours (every 6-12 hours)<br>
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| ❑ Immediate organ support
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| :❑ NIPPV/ IPPV
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| :❑ Vasopressors<br>
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| ❑ Urgent biliary tract drainage</div>}}
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| {{familytree | |,|-|^|-|.| | |!| | | |!| |}}
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| {{familytree | H01 | | H02 | |!| | | |!| | H01=Improvement|H02=No improvement within the first 24 hours}}
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| {{familytree | |!| | | |!| | |!| | | |!| |}}
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| {{familytree | I01 | | I02 | |!| | | |!| | I01=Finish antibiotic course|I02=Immediate biliary tract drainage within 24 hours}}
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| {{familytree | |`|-|v|-|'| | |!| | | |!| |}}
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| {{familytree | | | |`|-|-|-|-|+|-|-|-|'| |}}
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| {{familytree | | | | | | | | J01 | | | | J01=Treatment for etiology if still needed (endoscopic treatment, percutaneous treatment, or operative intervention)}}
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