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