Cholangitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Definition

Acute cholangitis is a morbid condition characterized by the acute infection and inflammation of an obstructed bile duct.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Cholangitis can be a life-threatening condition if it becomes suppurative and it must be treated as such irrespective of the causes.

Common Causes

• Cholecystolithiasis
• Ampullary tumor
• Bile duct tumor
• Gallbladder tumor
• Pancreatic tumor

Management

Shown below is a diagram depicting the management of cholangitis according to the Society for Surgery of the Alimentary Tract (SSAT) and Tokyo guidelines for management of cholangitis.

Management

Characterize the symptoms: ❑ RUQ abdominal pain ❑ Intermittent fever &/or chills ❑ Jaundice ❑ Lethargy or confusion

Examine the patient: ❑ Altered mental status ❑ Febrile ❑ Dehydrated ❑ Jaundice ❑ Hypotension ❑ Tachycardia ❑ Dyspnea ❑ Hypoxemia ❑ Abdominal tenderness

Order laboratory tests: ❑ CBC ❑ BMP ❑ CRP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase

Diagnostic criteria: ❑ Systemic inflammation ❑ Fever >38℃ and/or shaking chills ❑ WBC (×1000/μl) <4, or >10 ❑ CRP (mg/dl) ≥1 ❑ Cholestasis ❑ Jaundice with total bilirubin ≥2 (g/dl) ❑ ALP (IU) >1.5×STD ❑ GGT (IU) >1.5×STD ❑ AST (IU) >1.5×STD ❑ ALT (IU) >1.5×STD ❑ Imaging ❑ Biliary dilatation ❑ Evidence of etiology (stricture, stone, stent etc.)

❑ Hospital admission ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ Blood C&S ❑ Empiric IV antibiotics ❑ Ceftriaxone 1 g IV every 24 hours + Metronidazole 500 mg IV every 8 hours or ❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours ❑ Acute pain management ❑ Ketorolac 30-60 mg IM/IV single dose or ❑ Opioids until drainage or surgical intervention if ketorolac is contraindicated/pain not improving ❑ Assess severity

Grade 1 (Mild)

Grade 2 (Moderate)

Grade 3 (Severe)

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours)

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours) ❑ Immediate biliary tract drainage within 24-48 hours

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours) ❑ Immediate organ support ❑ NIPPV/ IPPV ❑ Vasopressors ❑ Urgent biliary tract drainage

Improvement

No improvement within the first 24 hours

Finish antibiotic course

Immediate biliary tract drainage within 24 hours

Treatment for etiology if still needed (endoscopic treatment, percutaneous treatment, or operative intervention)

^†ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic Metabolic Profile; CBC: Complete Blood Count; CBD: Common Bile Duct; CRP: C-reactive protein; ERCP: Endoscopic retrograde cholangiopancreatography; C&S: Culture & Sensitivity; GGT: Gamma-glutamyl transpeptidase; IM: Intramuscular; IPPV: Invasive Positive Pressure Ventilation; IV: Intravenous; IVF: Intravenous fluids; NIPPV: Non Invasive Positive Pressure Ventilation; NPO: Nil Per Oral; RUQ: Right Upper Quadrant; WBC: White Blood Cell; W/: With

Do's

• Perform blood cultures in all patients with suspicion or diagnosis of cholangitis in order to direct the antibiotic therapy.
• Biliary drainage is done with ERCP, which is the gold standard for both diagnosis and treatment of acute cholangitis. It is preferred over both surgical and percutaneous biliary drainage.
• Consider transferring the patient with grade 2 (moderate) and grade 3 (severe) severity to another hospital if immediate (within 24-48 hours) or urgent biliary tract drainage cannot be performed due to the lack of facilities or skilled personnel.
• Obtain cultures from bile or stents removed at ERCP for grade II (moderate) and III (severe) patients.
• Cholecystectomy should be performed for cholecystolithiasis after acute cholangitis has resolved.
• If ERCP drainage is not possible, percutaneous transhepatic biliary drainage or surgical decompression with CBD exploration and stone removal are the alternate options.
• Consider the placement of a T-tube drainage that allows biliary access for stone removal if the patient is unstable and stone removal is not possible.
• For large impacted stones where ERCP, percutaneous methods, and/or operative interventions are not possible, choledochoduodenostomy or choledochojejunostomy may be necessary.

Dont's

Occlusive cholangiography should not be performed in patients with acute cholangitis since it can lead to the development of septicemia.

References

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