Cholangitis resident survival guide

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

Overview

Cholangitis is an acute morbid condition characterized by the acute infection and inflammation of an obstructed bile duct.[1] Cholecystolithiasis is the most common cause of cholangitis and the biliary obstruction followed by the raised intrabiliary pressure favors the migration of bacteria from bile into the systemic circulation, leading to septicemia and thus increasing its risk as a life-threatening condition. Hospital admission, treatment of sepsis, empirical therapy followed by blood culture result based specific antibiotic therapy, risk stratification and establishing biliary drainage are the main stay in the management of cholangitis.

Causes

Life Threatening Causes

Cholangitis is a life-threatening condition and must be treated as such irrespective of the underlying cause.[1]

Common Causes

Management

Shown below is an algorithm depicting the management of cholangitis based on the 2012 evidence-based current surgical practice in management of calculous gallbladder disease according to the Society for Surgery of the Alimentary Tract (SSAT)[3] and 2013 progression of Tokyo guidelines and Japanese guidelines for management of acute cholangitis.[4]

 
 
 
 
 
 
Characterize the symptoms:
Right upper quadrant abdominal pain
❑ Intermittent fever and/or chills
Jaundice
Lethargy or confusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Altered mental status
Fever
Dehydration
Jaundice
Hypotension
Tachycardia
Dyspnea
Hypoxemia
❑ Abdominal tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
Complete blood count (CBC)
Basic metabolic panel (BMP)
C-reactive protein (CRP)
Total bilirubin
Direct bilirubin
Albumin
Aspartate transaminase (AST)
Alanine aminotransferase (ALT)
Alkaline phosphatase
Gamma-glutamyl transpeptidase (GGT)
Amylase
Lipase
Order imaging studies:
❑ Abdominal X-ray (KUB)
❑ Abdominal ultrasound
Computed tomography (CT)
Magnetic Resonance Imaging (MRI)
Magnetic resonance cholangiopancreatography (MRCP)
❑ Hepatobiliary iminodiacetic acid (HIDA) scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:[4]
❑ Systemic inflammation
Fever >38℃ and/or shaking chills
White blood cell (WBC) count (×1000/μl) <4, or >10
C-reactive protein (CRP) (mg/dl) ≥1

Cholestasis

Jaundice with total bilirubin ≥2 (g/dl)
Alkaline phosphatase (ALP) (IU) >1.5×STD
Gamma-glutamyl transpeptidase (GGT) (IU) >1.5×STD
Aspartate transaminase (AST) (IU) >1.5×STD
Alanine aminotransferase (ALT) (IU) >1.5×STD

❑ Imaging

❑ Biliary dilatation
❑ Evidence of etiology (stricture, stone, stent etc.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Hospital admission
❑ Nil per oral (NPO)
❑ Intravenous fluids (IVF) & correct electrolyte abnormalities
❑ Blood culture
❑ Empiric intravenous (IV) antibiotics[5]
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[4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Grade 1 (Mild)
 
Grade 2 (Moderate)
 
Grade 3 (Severe)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Nil per oral
❑ Intravenous fluids and correct electrolyte abnormalities
❑ Intravenous antibiotics (full dose)
❑ Intravenous pain management with analgesics
Assess severity
❑ Within 24 hours after diagnosis (every 6-12 hours)
❑ During the time zone of 24-48 hours (every 6-12 hours)
 
❑ Nil per oral
❑ Intravenous fluids and correct electrolyte abnormalities
❑ Intravenous antibiotics (full dose)
❑ Intravenous pain management with 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
 
❑ Nil per oral
❑ Intravenous fluids and correct electrolyte abnormalities
❑ Intravenous antibiotics (full dose)
❑ Intravenous pain management with 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

❑ Non invasive positive pressure ventilation (NIPPV)/ Intermittent positive pressure ventilation (IPPV)
❑ Vasopressors
❑ Urgent biliary tract drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
No improvement within the first 24 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Finish antibiotic course
 
❑ Immediate biliary tract drainage within 24 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the etiology if still needed:
❑ Endoscopic treatment, or
❑ Percutaneous treatment, or
❑ Operative intervention
 
 
 

Diagnostic Criteria

Shown below are the diagnostic criteria for acute cholangitis according to the Tokyo guidelines.[4]

  • The diagnosis is suspected in the case of the presence of one item in systemic inflammation with one item in either cholestasis or imaging findings.
  • The diagnosis is definite in the case of the presence of one item in systemic inflammation, one item in cholestasis and one item in imaging.
Clinical Manifestations Changes from the baseline
Systemic inflammation ♦ Fever >38℃ and/or shaking chills
♦ Evidence of inflammatory response:
- WBC (×1000/μl) <4, or >10
- CRP (mg/dl) ≥1
Cholestasis ♦ Jaundice with total bilirubin ≥2 (g/dl
♦ Abnormal liver function tests:
- ALP (IU) >1.5×STD
- GGT (IU) >1.5×STD
- AST (IU) >1.5×STD
- ALT (IU) >1.5×STD
Imaging findings ♦ Biliary dilatation
♦ Evidence of the etiology (stricture, stone, stent etc.) on imaging (abdominal X-ray: KUB, abdominal USG, CT scan, MRI, MRCP and HIDA scan)

Severity Assessment Criteria

The severity assessment criteria for acute cholangitis according to the Tokyo guidelines is as follows.[4]

Grade III Acute Cholangitis

Grade III or severe acute cholangitis is characterized by the onset of dysfunction in at least one of the following:

  • Cardiovascular system: decreased blood pressure that necessitate the administration of dopamine (>5 μg/kg/min) or norepinephrine
  • Neurological system: abnormal consciousness
  • Respiratory system: PaO2/FiO2 ratio <300
  • Renal system: serum creatinine >2.0 mg/dl, decreased urine output
  • Hepatic system: PT-INR >1.5
  • Hematological system: platelet count < 100,000/mm3

Grade II Acute Cholangitis

Grade II or moderate acute cholangitis is characterized by the presence of any two of the following:

  • Abnormal WBC count: >12,000/mm3, <4,000/mm3
  • Fever ≥39°C
  • Age ≥75 years
  • Elevated total bilirubin ≥5 mg/dl
  • Decreased albumin level <0.7 x STD

Grade I Acute Cholangitis

Grade I or mild acute cholangitis does not meet the criteria of neither grade II (moderate) or grade III (severe) acute cholangitis.

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.[6] It is preferred over both surgical and percutaneous biliary drainage.[7]
  • 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

  1. 1.0 1.1 Kimura, Y.; Takada, T.; Kawarada, Y.; Nimura, Y.; Hirata, K.; Sekimoto, M.; Yoshida, M.; Mayumi, T.; Wada, K. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.". J Hepatobiliary Pancreat Surg. 14 (1): 15–26. PMID 17252293. doi:10.1007/s00534-006-1152-y. 
  2. Lipsett, PA.; Pitt, HA. (1990). "Acute cholangitis.". Surg Clin North Am. 70 (6): 1297–312. PMID 2247816.  Unknown parameter |month= ignored (help)
  3. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease.". J Gastrointest Surg. 16 (11): 2011–25. PMID 22986769. doi:10.1007/s11605-012-2024-1.  Unknown parameter |month= ignored (help)
  4. 4.0 4.1 4.2 4.3 4.4 Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis.". J UOEH. 35 (4): 249–57. PMID 24334691.  Unknown parameter |month= ignored (help)
  5. Solomkin, JS.; Mazuski, JE.; Baron, EJ.; Sawyer, RG.; Nathens, AB.; DiPiro, JT.; Buchman, T.; Dellinger, EP.; Jernigan, J. (2003). "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.". Clin Infect Dis. 37 (8): 997–1005. PMID 14523762. doi:10.1086/378702.  Unknown parameter |month= ignored (help)
  6. Agarwal, N.; Sharma, BC.; Sarin, SK. (2006). "Endoscopic management of acute cholangitis in elderly patients.". World J Gastroenterol. 12 (40): 6551–5. PMID 17072990.  Unknown parameter |month= ignored (help)
  7. Lee, JG. (2009). "Diagnosis and management of acute cholangitis.". Nat Rev Gastroenterol Hepatol. 6 (9): 533–41. PMID 19652653. doi:10.1038/nrgastro.2009.126.  Unknown parameter |month= ignored (help)

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