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Understanding Cholangitis and Cholecystitis: A Simplified Guide

Updated: May 22

Antibiotic Dosing for Cholangitis and Cholecystitis

Condition

Medication

Dose

Route

Frequency

Duration

Mild (Grade I)

Ceftriaxone

2 grams

IV

Once daily

Until improvement, then oral (7-10 days)


Metronidazole

500 mg

IV

Every 8 hours

Until improvement, then oral (7-10 days)

Moderate (Grade II)

Ceftriaxone

2 grams

IV

Once daily

Minimum 7 days, reassess for oral switch


Metronidazole

500 mg

IV

Every 8 hours

Minimum 7 days, reassess for oral switch

Severe (Grade III)

Broad-spectrum antibiotics (e.g., Meropenem or Vancomycin)

Variable

IV

Based on specific antibiotic guidelines

As per clinical condition

Oral Antibiotics Upon Improvement

Medication

Dose

Route

Frequency

Duration

Cefixime

400 mg

Oral

Once daily

7-10 days

Metronidazole

500 mg

Oral

Every 8 hours

7-10 days

This table provides dosing information for ceftriaxone and metronidazole for cholangitis and cholecystitis, along with the switch to oral antibiotics upon clinical improvement.

Cholangitis

Diagnosis (Tokyo Guidelines 2018):

  • Suspected Acute Cholangitis:

    • Systemic Inflammation: Fever/chills, elevated WBC count, CRP

    • Cholestasis: Jaundice, abnormal liver function tests (ALP, GGT, AST, ALT)

    • Imaging: Biliary dilatation, etiology (stricture, stone, stent)

  • Definite Acute Cholangitis:

    • Confirmed if one item from each category (Systemic Inflammation, Cholestasis, Imaging) is present

Severity Grading:

  • Grade III (Severe): Organ dysfunction (e.g., cardiovascular, neurological, respiratory, renal, hepatic, hematological)

  • Grade II (Moderate): Two of the following: abnormal WBC count, high fever, age ≥75 years, hyperbilirubinemia, hypoalbuminemia

  • Grade I (Mild): Does not meet criteria for Grade II or III

Treatment:

  • Grade I (Mild):

    • Antibiotics: Ceftriaxone, Metronidazole; switch to oral antibiotics upon improvement (7-10 days)

    • Supportive Care: Hydration, pain management, antiemetics

    • Monitoring: Regular vital signs and liver function tests

    • Follow-Up: Outpatient follow-up

  • Grade II (Moderate):

    • Antibiotics: IV antibiotics for at least 7 days

    • ERCP: Within 24-48 hours

    • Supportive Care: Aggressive fluid resuscitation

    • Monitoring: Close monitoring in a high-dependency unit

    • Follow-Up: Regular outpatient follow-up with imaging

  • Grade III (Severe):

    • Antibiotics: Broad-spectrum IV antibiotics (consider vancomycin or meropenem)

    • ICU Admission: For close monitoring and supportive care

    • ERCP: Urgent, consider PTC if not feasible

    • Surgical Intervention: If ERCP/PTC unsuccessful

    • Supportive Care: Hemodynamic support, mechanical ventilation, renal replacement therapy

    • Monitoring: Continuous ICU monitoring

    • Follow-Up: Detailed follow-up with specialists

Cholecystitis

Diagnosis (Tokyo Guidelines 2018):

  • Clinical Criteria:

    • Local Signs: Murphy's sign, right upper quadrant mass/pain/tenderness

    • Systemic Signs: Fever, elevated CRP, elevated WBC count

  • Imaging Findings:

    • Gallbladder wall thickening (>4 mm), pericholecystic fluid, gallbladder distention, gallstones/sludge, positive sonographic Murphy's sign

Severity Grading:

  • Grade I (Mild): No organ dysfunction, mild local inflammation

  • Grade II (Moderate): Elevated WBC count, palpable mass, symptoms >72 hours, marked local inflammation

  • Grade III (Severe): Organ dysfunction (e.g., cardiovascular, neurological, respiratory, renal, hepatic, hematological)

Treatment:

  • Grade I (Mild):

    • Conservative Treatment: Antibiotics, supportive care

    • Elective Cholecystectomy: Planned

  • Grade II (Moderate):

    • Antibiotics: Supportive care

    • Early Cholecystectomy: Within 72 hours

  • Grade III (Severe):

    • ICU Admission: Management of organ dysfunction

    • Antibiotics: Supportive care

    • Cholecystectomy: Delayed or interval after stabilization

Supportive Treatment:

  • Antibiotics Examples:

    • Ceftriaxone, Metronidazole, Piperacillin/Tazobactam, Ciprofloxacin, Levofloxacin, Ampicillin/Sulbactam, Ertapenem

  • Pain Management: NSAIDs, opioids for severe pain

  • Hydration: IV fluids

  • NPO (Nil Per Os): To rest the gastrointestinal tract

Definitive Treatment:

  • Cholecystectomy:

    • Laparoscopic: Preferred for most patients

    • Open: For complicated cases or when laparoscopy is contraindicated

    • Percutaneous Cholecystostomy: For critically ill patients not fit for surgery

Conclusion

Both cholangitis and cholecystitis require prompt diagnosis and treatment to prevent complications. Following the Tokyo Guidelines for diagnosis and severity grading ensures systematically managing these conditions. Effective treatment strategies can improve patient outcomes and prevent serious complications. Stay updated with the latest guidelines to provide the best care for your patients.


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2 Comments


Mayta
Mayta
Jun 06

Charcot's triad is a set of three clinical signs associated with acute cholangitis, a potentially life-threatening infection of the biliary tract. The triad consists of:

  1. Fever: Often accompanied by chills, indicating the presence of infection.

  2. Jaundice: Yellowing of the skin and sclera due to elevated bilirubin levels, which suggests biliary obstruction.

  3. Right upper quadrant (RUQ) pain: This pain is typically sharp and localized to the area of the liver and gallbladder.

Extended Charcot's Triad: If confusion and hypotension are added to the classic triad, it is known as Reynolds' pentad, which indicates a more severe form of cholangitis and possible sepsis.

Clinical Relevance:

  • Diagnosis: Charcot's triad is used clinically to raise suspicion for acute cholangitis. However, the absence of one…

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Mayta
Mayta
May 30

ERCP ไปแล้ว อย่าลืมนัด LC ideally in 24 hrs

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