12. Acute Cholangitis

Definition

Fever, jaundice, abdominal pain (only 50-75% have all 3 of Charcot’s triad), sepsis, AMS.

Etiology

  • Top 3 causes: gallstones, malignancy, and benign strictures (including PSC); or, post-stent placement.
    • Rare: blood clots, liver flukes, Ascaris, recurrent pyogenic cholangitis.
  • Obstruction leading to ascending infection from duodenum more frequent cause than hematogenous spread from portal vein.
  • Mixed GNR, GPC (E. coli>Klebsiella>Enterobacter; Enterococcus; Bacteriodes, Clostridia).

Evaluation

  • CBC, CMP, INR, lipase, Upreg, blood cultures.
  • Diagnosis:
    • Cholestasis: bilirubin ≥ 2 or elevated liver enzymes.
    • Imaging showing biliary dilation or a cause of obstruction (stone, stricture, stent).
      • Options: US, CT, MRCP.
    • Evidence of systemic inflammation (fever, chills, WBC, CRP, thrombocytosis).
  • Severe suppurative cholangitis (20-30% mortality) defined by at least one of INR >1.5, PLT <100k, Cr >2 (oliguric), AMS, pressor requirement, or ARDS.
  • Moderate defined by any two of WBCs >12k or <4k, fever >39˚C, age >75, total bilirubin >5, hypoalbuminemia.

Management

  • Sepsis treatment, GI consult.
  • ERCP is indicated for clinical acute cholangitis within <24 hours if severe or within 24-48 hours if mild-moderate.
    • If ERCP unsuccessful, percutaneous drainage by IR may be recommended (i.e. percutaneous transhepatic biliary drain). This may lead to a staged ERCP (“rendezvous” procedure).
    • Surgical biliary drainage is last resort.
  • Antibiotics:
    • Low to moderate risk: ertapenem 1g daily vs. piperacillin/tazobactam 3.375mg IV q6h vs. cephalosporin + metronidazole or ciprofloxacin + metronidazole.
    • High risk (cover Pseudomonas): piperacillin/tazobactam 4.5g q6h vs. meropenem 1g q8h IV vs. cefepime vs. ceftazidime + metronidazole.
    • If high risk + hospital-acquired: same as high risk above, PLUS ampicillin 2g q4 OR vancomycin q12 if there is concern for enterococcus.
    • Duration: 4-5 days after source control.
  • Elective cholecystectomy is indicated in patients with gallstones after resolution of cholangitis.

Key Points

  • Fever, jaundice, and abdominal pain suggest acute cholangitis, which when severe has 20-30% mortality.
  • Most common causes are stones, malignancy, or benign strictures.
  • Involve GI early: urgent or semi-urgent ERCP is indicated for clinical acute cholangitis.
  • Elective cholecystectomy is indicated for cholangitis due to gallstones after acute illness has resolved.

 

Marple JT et al. Role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010;71:1

Solomkin JS et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: IDSA Guidelines. Clin Infect Dis 2010;50:133