Clinical signs and symptoms
- Abdominal pain
- White blood cell
- C-reactive protein
- Total bilirubin
- Direct bilirubin
- Alkaline phosphatase
- Gamma-glutamyl transpeptidase
- Aspartate aminotransferase
- Alanine aminotransferase
- Endoscopic ultrasound (EUS)
- Biliary dilatation
- Thickening of the bile duct wall
- Papillitis and transient hepatic attenuation differences
Historically, US has been the initial modality for evaluating for biliary obstruction in the setting of suspected cholangitis. However, research and recommendations published over the last decade have challenged this approach, and data have become increasingly supportive of the use of computed tomography (CT) as the initial imaging study of choice to confirm biliary obstruction and identify its source.
Biliary drainage and antibiotic therapy for 3-5 days
The type and timing of biliary drainage should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques, such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and open surgical drainage.
– Endoscopic retrograde cholangiopancreatography (ERCP). It plays a central role in the management of biliary obstruction in patients with acute cholangitis and is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis. Endoscopic transpapillary options during ERCP: biliary stent or nasobiliary drain placement.
– Percutaneous biliary drainage (PTBD). It should be reserved for patients in whom ERCP fails. PTBD can lead to significant complications, including biliary peritonitis, haemobilia, pneumothorax, hematoma, liver abscesses, and patient discomfort related to the catheter.
– Open drainage. It should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed.
Empiric antibiotic regimens. Normal renal function
One of following antibiotics
Amoxicillin/clavulanate* 1.2-2.2 g 8-hourly
Piperacillin/Tazobactam* 4.5 g 6-hourly (critically ill patients)
Ceftriaxone 2 g 24-hourly + Metronidazole 500 mg 6-hourly
Cefotaxime 2g 8-hourly + Metronidazole 500 mg 6-hourly
In patients with beta-lactam allergy
A fluoroquinolone-based regimen
Ciprofloxacin* 400 mg 8/12-hourly + Metronidazole 500 mg 6- hourly
In patients at high risk for infection with community-acquired ESBL-producing Enterobacteriaceae
One of the following antibiotics
Tigecycline* 100 mg LD, then 50 mg 12-hourly (Carbapenem-sparing strategy)
Ertapenem 1 g 24 hourly (No active against Pseudomonas aeruginosa)
Meropenem 1 g 8-hourly (only in patients with septic shock)
Doripenem 500 mg 8-hourly (only in patients with septic shock)
Imipenem/Cilastatin 500 mg 6-hourly (only patients with septic shock)
*High biliary penetration activityIn patients at high risk for infection with Enterococci including immunocompromised patients or patients with recent antibiotic exposure consider use of Ampicillin 2 g 6-hourly if the patients are not being treated with Piperacillin/Tazobactam or Imipenem/Cilastatin (active against ampicillin-susceptible enterococci) or Tigecycline.