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Acute cholangitis

Definition
Acute cholangitis is a bacterial infection that occurs in the setting of biliary obstruction, characterized by fever, abdominal pain, and jaundice.
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Pathophysiology
The pathophysiology of acute cholangitis involves a blockage in the bile ducts, often due to choledocholithiasis or strictures. This blockage allows for the retrograde migration of bacteria from the intestine into the biliary system, leading to bacterial overgrowth and subsequent immune response, which results in inflammation and infection of the bile ducts.
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Epidemiology
The incidence of acute cholangitis in the US is estimated at 3,000 per 100,000 person-years.
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Disease course
Clinically, patients with acute cholangitis often present with the Charcot triad of fever, jaundice, and RUQ pain. In severe cases, patients may also exhibit signs of sepsis, such as hypotension and altered mental status.
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Prognosis and risk of recurrence
The prognosis can vary and is influenced by factors such as disease severity, the patient's overall health, and the timeliness and effectiveness of treatment. Certain laboratory values, such as a WBC count > 20,000 cells/µL and a TBIL level > 10 mg/dL, have been identified as independent prognostic factors for adverse outcomes.
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Key sources
The following summarized guidelines for the evaluation and management of acute cholangitis are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2015), the American College of Radiology (ACR 2019), the Tokyo Guidelines (TG 2018), and the European Association for the Study of the Liver (EASL 2016).
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Guidelines

1.Diagnostic investigations

Clinical evaluation
Elicit medical history and perform physical examination to identify the characteristic symptoms of gallbladder stones, such as episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics.
B
Evaluate for common bile duct stones in patients with jaundice, acute cholangitis, or acute pancreatitis.
A
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  • Laboratory tests

  • Abdominal ultrasound

  • ERCP

  • MRCP

  • EUS

2.Medical management

Antibiotics
As per TG 2018 guidelines:
Administer antibiotics for 4-7 days in patients with acute cholangitis, once the source of infection is controlled.
B
Administer antibiotics according to the following regimens in patients with cholangitis:
Situation
Guidance
Grade 1
Penicillins - do not use ampicillin + sulbactam if the resistance rate is > 20%
Cephalosporins - cefazolin/cefotiam/cefuroxime/ceftriaxone/cefotaxime +/- metronidazole, cefmetazole, cefoxitin, flomoxef, cefoperazone + sulbactam
Carbapenems - ertapenem
Fluoroquinolones - ciprofloxacin/levofloxacin/pazufloxacin +/- metronidazole, moxifloxacin
Grade 2
Penicillins - piperacillin + tazobactam
Cephalosporins - ceftriaxone/cefotaxime/cefepime/cefozopran/ceftazidime with or without metronidazole, cefoperazone + sulbactam
Carbapenems - ertapenem
Fluoroquinolones - ciprofloxacin/levofloxacin/pazufloxacin +/- metronidazole, moxifloxacin
Grade 3
Penicillins - piperacillin + tazobactam
Cephalosporins - cefepime/ceftazidime/cefozopran +/- metronidazole
Carbapenems - imipenem + cilastatin, meropenem, doripenem, ertapenem
Monobactams - aztreonam +/- metronidazole
Healthcare-associated cholangitis
Penicillins - piperacillin + tazobactam
Cephalosporins - cefepime/ceftazidime/cefozopran +/- metronidazole
Carbapenems - imipenem/cilastatin, meropenem, doripenem, ertapenem
Monobactams - aztreonam +/- metronidazole
B

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  • Spasmolytics and opioids

  • NSAIDs

3.Therapeutic procedures

Biliary decompression: as per ACR 2019 guidelines, place an endoscopic internal biliary catheter with a removable plastic stent or a percutaneous internal/external biliary catheter as the initial therapeutic procedure in patients with dilated bile ducts and suspected biliary sepsis or acute cholangitis. Decide between procedures depending on the patient's anatomy and availability of resources and institutional preferences.
B

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  • Endoscopic sphincterotomy

  • Percutaneous or endoscopic biliary drainage

  • Litholysis and lithotripsy

4.Perioperative care

Preoperative evaluation
Avoid obtaining routine preoperative tests other than abdominal ultrasound to confirm the presence of gallstones in patients planned to undergo cholecystectomy.
D
Consider obtaining liver biochemical tests before elective cholecystectomy in individually selected patients.
C

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  • Intraoperative cholangiography

  • Postoperative evaluation

5.Surgical interventions

Indications for cholecystectomy, symptomatic stones: perform cholecystectomy as the preferred option for treatment of patients with symptomatic gallbladder stones.
B

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  • Indications for cholecystectomy (concomitant abdominal surgery)

  • Indications for cholecystectomy (acute biliary pancreatitis)

  • Indications for cholecystectomy (bile duct stones)

  • Choice of surgical approach

  • Timing for cholecystectomy

  • Intraoperative management of bile duct stones

  • Intraoperative management of bile duct injuries

6.Specific circumstances

Asymptomatic patients: avoid offering routine treatment in patients with asymptomatic gallbladder stones.
D
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  • Elderly patients

  • Pregnant patients

7.Preventative measures

Lifestyle modifications: advise healthy lifestyle and food, regular physical activity and maintenance of an ideal body weight to prevent cholesterol gallbladder stones and symptomatic gallstones.
B

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  • UDCA

  • Prophylactic cholecystectomy

  • Measures with no evidence for benefit