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    Ascending Cholangitis

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    Last Updated Jan 19, 2022
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    By Julian Marsden

    Context

    • Ascending cholangitis (AC) is a clinical syndrome resulting from biliary obstruction and bacterial growth in the bile.
    • Most frequent cause of biliary obstruction is choledocholithiasis, but other causes include post-ERCP, benign or malignant strictures, and sclerosing cholangitis.
    • Elevated intraductal pressure from obstruction allows for cholangio-venous reflux and translocation of bacteria into vascular system.
    • Early diagnosis and prompt source control/antimicrobial therapy are critical in limiting incidence of septic shock and multiple organ failure.

    Clinical Presentation

    • Classic triad of fever, jaundice, and RUQ/abdominal pain although absence of abdominal pain does not exclude diagnosis of AC.
    • Milder cases may mimic acute cholecystitis.
    • Maintain suspicion of AC in unspecified sepsis with possible abdominal source.

    Empiric Therapy / Initial Laboratory Investigations

    • Initial bloodwork should include liver enzymes, C-reactive protein (CRP) and serum lactate.
    • Draw blood cultures x2 in all cases of suspected AC.
    • Empiric therapy should be administered as soon as diagnosis of AC is suspected.

    Imaging

    • First-line imaging should be abdominal ultrasound to confirm stones or bile duct dilatation.
    • If formal ultrasonography unavailable OR abdominal U/S is normal in suspected AC, proceed directly to abdominal CT if available.
    • If above studies do not yield definite diagnosis, consider early consultation and possible transfer for magnetic resonance cholangiopancreatography (MRCP).

    2018 Tokyo Guidelines Diagnostic Criteria

    • Definite diagnosis includes ALL of the following:
      • Systemic inflammation
        • A-1 Fever and/or shaking chills, OR
        • A-2 WBC <4 or >10 or CRP >1
      • Cholestasis
        • B-1 Jaundice, OR
        • B-2 Liver enzymes > 1.5 x STD
      • Imaging
        • C-1 Biliary dilatation, OR
        • C-2 Evidence of etiology on imaging (stricture, stone, stent etc.)
    • Sensitive (91.8%) but false positives (5.9%) include acute cholecystitis.
    • Limited ability to diagnose milder cases.

    Severity Grading

    • Grade I (mild) acute cholangitis does not meet Grade II/III criteria at time of diagnosis but can rapidly progress.
    • Grade II (moderate) acute cholangitis with two of the following conditions:
      • WBC > 12,000/mm3 or < 4,000/mm3
      • T > 39C
      • Age > 75 years old
      • Total bilirubin > 85.5 umol/L
      • Serum albumin < 0.7 x STD
    • Grade III (severe) acute cholangitis with end-organ dysfunction, including any of the following:
      • Cardiovascular: hypotension requiring dopamine >5 ug/kg per min or NEP
      • Neurological: altered level of consciousness
      • Respiratory: PaO2/FiO2 <300
      • Renal: oliguria or serum Cr > 188 umol/L
      • Hepatic: PT-INR > 1.5
      • Hematologic: Platelet < 100,000/mm3
    • 30-day all-cause mortality rates are 2.4%, 4.7% and 8.4% by severity grades I-III respectively.

    Antimicrobial Therapy

    • Common microorganisms include:
      • Escherichia coli (31-44%)
      • Klebsiella (9-20%)
      • Pseudomonas (0.5-19%)
      • Enterobacter (5-9%)
      • Enterococcus (3-34%)
      • Streptococcus (2-10%)
    • For Grade I disease, start with Ceftriaxone 1-2g IV q24h +/- Metronidazole 500mg IV/PO q12h.
    • If beta lactam allergy, use Ciprofloxacin 400mg IV q12h instead.
    • For Grade II/III disease, start with Piperacillin-tazobactam 3.375g IV q6h
      • If suspect Pseudomonas, use Piperacillin-tazobactam 4.5g IV q6h
      • If extended-spectrum beta lactamase (ESBL) risk factors, use Meropenem 500mg IV q6h instead
    • If Grade III or healthcare associated AC, consider adding Vancomycin; If known VRE, switch to Linezolid 600mg IV/PO q12h.
    • Duration of antimicrobial therapy for 4-7 days after source control
      • If gram positive cocci (enterococcus, streptococcus), minimum 2 weeks recommended.
      • If hepatic abscess, continue antimicrobial therapy until complete resolution.

    Management

    • All AC require admission, antimicrobial therapy, and fluid management +/- GI/general surgery.
    • Grade I:
      • Transfer for biliary drainage if they fail to respond to initial treatment within 24h.
      • If high risk of choledocholithiasis, consult GI/general surgery for likely ERCP with elective cholecystectomy.
      • If moderate risk of choledocholithiasis, consider GI/general surgery consultation for MRCP first.
    • Grade II:
      • Early consultation with GI/general surgery for early biliary drainage within 24-48h.
      • Clinicians must maintain low threshold to initiate necessary cardiorespiratory support.
    • Grade III:
      • Urgent early consultation with intensivist and high priority transfer to hospital that is equipped to perform ERCP/percutaneous biliary drainage and/or critical care.

    Quality Of Evidence?

    Justification

    • Mortality benefit of early drainage in Grade II disease: Multiple case series studies.
    Moderate
    • Diagnostic criteria: Two retrospective case series studies have shown sensitivity as screening tool, but no studies have evaluated for specificity.
    • Duration of antimicrobial therapy: Based primarily on expert opinion.
    Low

    Related Information

    OTHER RELEVANT INFORMATION

    1. 2018 Tokyo Guidelines for Acute Cholangitis: Diagnostic criteria and severity grading


    Reference List

    1. 2018 Tokyo Guidelines for Acute Cholangitis: Diagnostic criteria and severity grading.


    2. Kiriyama S, Takada T, Hwang T-L, Akazawa H, Miura F, Gomi H, et al. Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study. J Hepatobiliary Pancreat Sci. 2017; 24:329-37


    3. 2018 Tokyo Guidelines for Acute Cholangitis: Initial management of acute biliary infection


    4. 2018 Tokyo Guidelines for Acute Cholangitis: Antimicrobial therapy for acute cholangitis


    Print Summary

    RESOURCE AUTHOR(S)

    Dr Julian Marsden

    Clinical Resources Lead

    DISCLAIMER

    The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.

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