Management of Ascending Cholangitis
Section snippets
Pathogenesis
Acute ascending cholangitis is a clinical syndrome caused by bacterial infection superimposed upon an obstructed biliary tree. The term ascending cholangitis refers to the presumed origin of the bacteria, which is believed to ascend the biliary tree from the duodenum [8]. Biliary infection also can be introduced through the portal venous system and peri-ductal lymphatics, although this route is likely less common [12], [13]. Other theories suggest bacterial translocation from the colon may
Causes of biliary obstruction leading to cholangitis
Choledocholithiasis is the most common cause of biliary obstruction leading to cholangitis in Western countries (Fig. 1). Bile duct stones typically cause intermittent obstruction, likely allowing bacteria to enter the bile duct from the duodenum, and stones can act as a nidus for bacterial adhesion and growth. Gallstones are quite common, affecting approximately 15% of North Americans, with much higher incidence in Hispanic and Native American populations [24]. Of all patients who have
Pathogenic organisms
Common organisms causing acute cholangitis are usually those found in the large bowel. They include Escherichia coli in 25% to 50% of cases, Klebsiella in 15% to 20% of cases, and Enterobacter species in 5% to 10% of cases [8]. Enterococcus is the most common gram-positive bacterium contributing to cholangitis, occurring in 10% to 20% of cases. Anaerobes such as Bacteroides and Clostridia also may cause cholangitis, and they are usually present as a mixed infection (Fig. 2). Elderly patients
Clinical presentation
Charcot's triad of right upper quadrant pain, jaundice, and fever historically has been reported in up to 50% to 70% of patients with cholangitis, but recent series of have found only 15% to 20% of patients with these classic findings [1], [2], [3], [4], [5], [6]. The addition of hypotension and altered mental status defines Reynold's pentad, which is found in an even smaller percentage (Box 1). Thus, many patients with ascending cholangitis do not present with classic signs and symptoms.
Imaging studies
Establishing the diagnosis of acute ascending cholangitis involves careful examination of clinical signs, symptoms, and laboratory studies, but imaging often establishes the diagnosis. Transabdominal ultrasound is the initial imaging study of choice. Ultrasound is highly sensitive and specific for examining the gallbladder and assessing bile duct dilatation, but it can miss stones in the distal bile duct commonly. One study comparing ultrasound with various other imaging modalities including
Initial treatment
Rehydration with intravenous fluids, correcting any electrolyte abnormalities or coagulopathy and starting an appropriate antibiotic are crucial in early management of cholangitis. Careful monitoring in the ICU should be considered if the patient shows any sign of clinical instability. Antibiotic choice should be tailored to the individual patient. There are few data regarding the threshold for safety of international normalized ratio (INR) or platelet counts when performing ERCP with
Antibiotics
Ampicillin in combination with gentamicin traditionally has been the antibiotic combination of choice for treating cholangitis. Because of emerging antimicrobial resistance and the risk of nephro- and ototoxicity associated with gentamicin, these largely have been replaced by other antibiotics such as ciprofloxacin or broad- spectrum penicillins, as there are ample data suggesting these safer alternative antimicrobials are more effective. Broad-spectrum penicillins have been shown to adequately
Endoscopic approach to cholangitis
Drainage is the focus of therapy for cholangitis, and endoscopic biliary drainage with ERCP is the best method to achieve biliary drainage. Complications from ERCP are well known, including pancreatitis, bleeding, and perforation [41]. ERCP is successful in over 98% of patients and is considerably safer and has many advantages over surgical or percutaneous drainage techniques [40]. In a landmark study by Lai and colleagues, 82 patients who had severe cholangitis were randomized to either
Timing of endoscopic retrograde cholangiopancreatography
Timing of ERCP should be based on the patient's clinical status. All patients should be optimized medically with early initiation of intravenous fluids, analgesics, and antibiotics. Coagulopathy should be corrected if possible. Immunocompromised patients and patients who have signs of sepsis that do not quickly resolve with fluids should undergo urgent ERCP. In clinically stable patients who improve with conservative measures, ERCP can usually be delayed for 24 to 48 hours as long as the
Cholecystectomy
Several studies have shown that in patients who have cholangitis in the setting of choledocholithiasis, cholecystectomy should be performed electively after bile duct clearance to prevent further stone obstruction or cholangitis unless the patient has prohibitive contraindications to surgical intervention because of the high risk of recurrence [59], [60], [61]. Surgical intervention in patients who have acute cholangitis carries a substantial morbidity and mortality, however, and should be
Cholangitis in the setting of malignant obstruction
Malignant obstruction of the biliary tree uncommonly leads to cholangitis unless prior biliary instrumentation has been performed. After palliative ERCP with stenting for symptomatic jaundice, patients who have long-term indwelling biliary stents are at very high risk for developing cholangitis, as stent obstruction inevitably occurs. Several modifications have been made to improve plastic stent function and patency, from application of nonstick coating, double-layer construction, and removal
Percutaneous transhepatic cholangiography and surgical drainage
When ERCP is not possible because of altered surgical anatomy or duodenal obstruction, percutaneous transhepatic cholangioscopy (PTC) with percutaneous biliary drain placement is the primary method of decompressing the infected bile duct. PTC is successful in accessing and draining the biliary system up to 90% of patients with biliary obstruction [64]. One advantage of PTC is that it can be performed under local anesthesia and is readily available in most hospitals; however this procedure is
Summary
Acute ascending cholangitis can be a life threatening emergency. Early diagnosis can be challenging, as classic findings such as abdominal pain, jaundice, fever, altered mental status, and hypotension are not found in most patients. Initial therapy, including rehydration with intravenous fluids and broad-spectrum antibiotics should be started promptly. Antibiotic coverage is directed at gram-negative enteric organisms, with additional coverage for Enterococcus and mixed anaerobes in the
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