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]

Overview

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

Common Causes

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

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) and 2013 progression of Tokyo guidelines and Japanese guidelines for management of acute cholangitis.

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: ❑ 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 ❑ 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)

❑ 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.

• 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.

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. 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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