This is a slide on approach and mangement of cholangitis which is a surgical emergency, this slide is based on the Tokyo guideline - 2018 and has references from sabiston text book of surgery

1. Approach and management to
cholangitis
Dikshanta Acharya
Department of Surgery
Patan Academy of Health Sciences

2. Introduction
• Occurs when biliary obstruction results in cholestasis and biliary infection
• Benign causes (often bile duct stones) or tumor
• Elevated pressure within the biliary system  flushes the microorganisms
or endotoxins from the infected bile into systemic circulation  SIRS
• Mortality risk is high if the condition is not treated
• Need to be able to reliably diagnose and assess the severity of cholangitis

3. Main bile duct
6 mm in diameter; 10-12 cm in length
A. Upper- common hepatic duct (CHD)
1. Situated above cystic duct
2. Hepatic artery -> right branch of hepatic artery which crosses posteriorly to CHD (
in 20 % crosses anteriorly)
3. Cystic artery branch of right branch of hepatic artery can cross CHD anteriorly or
posteriorly
B. Lower- common bile duct
• After union of CHD and cystic duct
• 7.5 cm length
• Divided into – hilar, supraduodenal and retropancreatic

4. Blood supply of bile duct
• Right branch of the hepatic artery (a),
• 9 o’clock artery (b),
• retroduodenal artery (c),
• left branch of the hepatic artery (d),
• hepatic artery (e),
• 3 o’clock artery (f),
• common hepatic artery (g),
• gastroduodenal artery (h).

5. Clinical manifestations
• Reynauds' pentad :
• Collection of signs and symptoms consistent with obstructive ascending
cholangitis, a serious infection of the biliary tract.
• Charcot's triad + shock + altered mental status.
• Patients with acute cholangitis can also present with complications from
bacteremia, including hepatic abscess, sepsis, multiple organ system dysfunction,
and shock.
Charcot’s traid
(all 3 occur in <50% cases)
Fever Abdominal
pain
Jaundice
(least common)

6. TG-18 Guidelines : Diagnosis
• A. Systemic Inflammation
• B. Cholestasis
• C. Imaging

7. Systemic Inflammation
• A1 - Fever / or shaking chills
• Defined as body temperature > 38 °C
• A2 - Laboratory Evidence of Inflammatory Response
• WBC count(x1000/ul) <4 or >10
• CRP (mg/dl) ≥1

8. Cholestasis
• B1 – Jaundice
• Total Bilirubin ≥2 (mg/dL)
• B2- Abnormal Liver Function Test
• ALP >1.5 × STD
• AST >1.5 × STD
• ALT >1.5 × STD
• γGT >1.5 × STD

9. Imaging
• C1 – Biliary dilatation
• C2 – Evidence of the etiology on imaging (stricture, stone, stent etc.)

10. Lab investigations
• CBC (elevated TLC with neutrophil predominance),
• LFT (shows cholestatic pattern - ↑ed ALP, GGT and conjugated
bilirubin)
• PT/INR - Derangement
• Electrolytes
• Pregnancy test
• Blood cultures (in all patients )
• Cultures should also be obtained from bile or stents removed at ERCP

11. • Leukocytosis with abnormal liver panel is common.
• 1st screening test  USG (shows dilatation of biliary tree/ bile duct stones).
• CT Scan  useful to know site of obstruction.
• MRCP - > If USG and CT scan are unclear. It helps in identifying cause of
biliary obstruction.
• Most valuable (diagnostic + therapeutic)  Cholangiography through ERCP
or PTCs
• EUS - > occasionally used as a diagnostic tool for evaluating suspected
choledocholithiasis in patients who cannot undergo MRCP and can be
therapeutic.

12. Severity grading
• Mild acute cholangitis
• Moderate acute cholangitis
• Severe acute cholangitis

13. Severe (suppurative) cholangitis
• Onset of dysfunction in at least any one of the following
organs/systems:
• Cardiovascular dysfunction – Hypotension requiring dopamie ≥5
micrograms/kg per min, or any dose of norepinephrine
• Neurological dysfunction – Disturbance of consciousness
• Respiratory dysfunction – PaO2/FiO2 ratio <300
• Renal dysfunction – Oliguria, serum creatinine >2.0 mg/dl
• Hepatic dysfunction – Prothrombin time-international normalized ratio >1.5
• Hematological dysfunction – Platelet count <100,000/mm

14. Moderate acute cholangitis
• associated with any two of the following:
• Abnormal WBC count (>12,000/mm3, <4,000/mm3)
• Fever 39°C (102.2°F)
• Age (≥75 years)
• Hyperbilirubinemia (total bilirubin ≥5 mg/dl)
• Hypoalbuminemia

15. • Mild acute cholangitis — Mild acute cholangitis does not meet the
criteria for moderate or severe cholangitis at initial diagnosis.

16. Management
• General measures:
• Admission in hospital.
• Based on the severity, intravenous hydration and correction of associated
electrolyte disorders
• IV antibiotics
• Analgesics for pain control.
• Close monitoring for organ dysfunction and septic shock.
• Definitive:
• Emergent decompression of the biliary tree (endoscopic/ percutaneous
drainage > surgical intervention).

17. IV antibiotics
• Empiric regimens for intra-abdominal infections include
antimicrobials with activity against enteric streptococci, coliforms,
and anaerobes
• Choice of antibiotics - whether the infection is community-acquired
versus healthcare-associated,

18. A) For patients with community-acquired
acute cholangitis of low to-moderate risk
Single-agent regimen
Piperacillin-tazobactam* 3.375 g IV every 6 hours
Combination regimen with metronidazole*
One of the following:
Cefazolin 1 to 2 g IV every 8 hours
or
Cefuroxime 1.5 g IV every 8 hours
or
Ceftriaxone 2 g IV once daily
or
Cefotaxime 2 g IV every 8 hours
or
Ciprofloxacin
400 mg IV every 12 hours or
500 mg PO every 12 hours
or
Levofloxacin 750 mg IV or PO once daily
Plus:
Metronidazole¶ 500 mg IV or PO every 8 hours

19. B) For patients with community-acquired
acute cholangitis of high risk
Single-agent regimen
Imipenem-cilastatin 500 mg IV every 6 hours
Meropenem 1 g IV every 8 hours
Doripenem 500 mg IV every 8 hours
Piperacillin-tazobactam 4.5 g IV every 6 hours
Combination regimen with metronidazole
ONE of the following:
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
PLUS:
Metronidazole 500 mg IV or orally every 8 hours

20. C) For patients with healthcare-associated
acute cholangitis
Single-agent regimen
Imipenem-cilastatin 500 mg IV every 6 hours
Meropenem 1 g IV every 8 hours
Doripenem 500 mg IV every 8 hours
Piperacillin-tazobactam 4.5 g IV every 6 hours
Combination regimen
ONE of the following:
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
PLUS:
Metronidazole 500 mg IV or orally every 8 hours
PLUS ONE of the following (in some cases*):
Ampicillin 2 g IV every 4 hours
OR
Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours

21. Definitive : Biliary drainage
• 70-80 % of patients respond to initial antibiotic therapy
• Mild to moderate cholangitis, biliary drainage should be performed
within 24 to 48 hours
• Mild to moderate cholangitis that fail to respond to conservative
management for 24 hours, and patients with severe cholangitis
require urgent (within 24 hours) biliary decompression

22. Choice
• Endoscopic Drainage
• Percutaneous Drainage
• Surgical Drainage

23. Endoscopic Drainage
• Sphincterotomy with stone extraction and/or stent insertion
• Associated with significantly lower overall rates of mortality and
morbidity compared with surgical decompression (10% vs 50%)
• Large or impacted stones require mechanical lithotripsy or
cholangioscopy with electrohydraulic or laser lithotripsy for
fragmentation prior to removal

24. • Patients with coagulopathy - Placing a stent within the bile duct
without first performing a sphincterotomy
• Placement of a nasobiliary catheter
• EUS-guided cholangiopancreatography with biliary drainage and
stent placement - if ERCP fails or not possible due to obstructing
tumors

25. Percutaneous Drainage
• When endoscopic drainage is unavailable or unsuccessful
• Transhepatic insertion of a needle into a bile duct
• Drainage of infected bile, extraction of biliary tract stones, dilation of
benign biliary strictures, or placement of a stent across a malignant
stricture

26. • Requires a dilated biliary system
• Require International normalized ratio (INR) <1.8 (and ideally <1.5)
and platelet count ≥50,000/microL
• Percutaneous cholecystostomy tube in patients with an intact
gallbladder and non dilated biliary system

27. Surgical Drainage
• Reserved for patients in whom other methods of biliary drainage
cannot be performed or have failed
• Obstructing stone - Accomplished with open or laparoscopic common
bile duct exploration, with choledocholithotomy, with or without
placement of a T tube
• Hemodynamically stable patients can undergo a cholecystectomy at
the same time

28. • Malignant biliary obstruction-
• resection (eg, Whipple or bile duct resection),
• Bypass (eg, hepaticojejunostomy),
• T tube drainage
• Iatrogenic bile duct injury/obstruction - Hepaticojejunostomy

29. Addressing the underlying Cause
• Gallstone disease – elective cholecystectomy after the resolution of
cholangitis
• Benign biliary stricture – Endoscopic or surgical repair
• Malignant stenoses, management -stent placement at the time of
endoscopic biliary drainage

30. Approach

33. Transfer Criteria
• Severe Acute Cholangitis
• Patients who require emergency biliary drainage as well as critical care should
be transferred immediately to where this can be provided
• Moderate Acute Cholangitis
• Patients should be treated in a hospital where biliary drainage can be
performed
• Mild Acute Cholangitis
• If no response to initial treatment (within 24 hours), biliary drainage

34. Management Bundle
• When acute cholangitis is suspected, perform a diagnostic
assessment every 6 to 12 h using TG18 diagnostic criteria until a
diagnosis is reached
• Abdominal Ultrasonography, followed by a CT scan, MRI, MRCP, and
HIDA scan as required
• As soon as a diagnosis has been made, provide initial treatment.

35. • Initial management consists of sufficient fluid replacement,
electrolyte compensation, and intravenous administration of
analgesics and full-dose antimicrobial agents
• In patients with Grade I (mild) disease, if no response to the initial
treatment is observed within 24 h, perform biliary tract drainage
immediately

36. • In Grade II (moderate) disease, perform biliary tract drainage
immediately along with the initial treatment
• If early drainage cannot be performed because of a lack of facilities or skilled
personnel, consider transferring the patient
• In Grade III (severe) disease, perform urgent biliary tract drainage
along with the initial treatment and give general supportive care
• If early drainage cannot be performed because of a lack of facilities or skilled
personnel, consider transferring the patient

37. • In patients with Grade III (severe) disease, supply organ support (e.g.
noninvasive/invasive positive pressure ventilation, use of
vasopressors and antimicrobial agents) immediately.
• Perform blood culture or bile culture, or both, in Grade II (moderate)
and III (severe) patients.

38. • Consider treating the etiology of acute cholangitis with endoscopic,
percutaneous, or operative intervention once the acute illness has resolved
• Cholecystectomy should be performed for cholecystolithiasis after the
acute cholangitis has resolved
• If the hospital is not equipped to perform endoscopic or percutaneous
transhepatic biliary drainage or provide intensive care, transfer patient
with moderate or severe cholangitis to a hospital capable of providing
these treatments.

39. References
• Blumgart’s Surgery of Liver, Biliary Tract and Pancreas – 7th edition
• Tokyo Guidelines 2018: initial management of acute biliary infection
and flowchart for acute cholangitis
• Uptodate

40. • Thank you