top of page

Understanding Cholangitis: Diagnosis, Severity Grading, and Treatment

Diagnosing Cholangitis: The Tokyo Guidelines

Category

Criteria

Details

Suspected Acute Cholangitis



Systemic Inflammation

Fever and/or shaking chills

Laboratory evidence of an inflammatory response (elevated WBC count, CRP, etc.)

Cholestasis

Jaundice

Abnormal liver function tests (elevated ALP, GGT, AST, ALT)

Imaging

Biliary dilatation

Evidence of the etiology (e.g., stricture, stone, stent, etc.)

Definite Acute Cholangitis

Diagnosis confirmed if one item from each category is present


Grading the Severity of Cholangitis

Grade

Criteria

Details

Grade III (Severe)

Presence of organ/system dysfunction

Any one of the following:


Cardiovascular:

Hypotension requiring dopamine ≥5 μg/kg per minute, or any dose of norepinephrine


Neurological:

Disturbance of consciousness


Respiratory:

PaO2/FiO2 ratio <300


Renal:

Oliguria, serum creatinine >2.0 mg/dL


Hepatic:

PT-INR >1.5


Hematological:

Platelet count <100,000/mm³

Grade II (Moderate)

Any two of the following:



Abnormal white blood cell count:

>12,000 or <4,000/mm³


High fever:

≥39°C


Age:

≥75 years


Hyperbilirubinemia:

Total bilirubin ≥5 mg/dL


Hypoalbuminemia:

<STD×0.7

Grade I (Mild)

Does not meet criteria for Grade II or III


Orders Based on Severity

Grade

Intervention

Details

Grade I

Antibiotics

Ceftriaxone 2 grams IV once daily, Metronidazole 500 mg IV every 8 hours; switch to oral antibiotics upon clinical improvement for 7-10 days.


Supportive Care

Hydration, pain management, antiemetics as needed.


Monitoring

Regular monitoring of vital signs and liver function tests.


Follow-Up

Outpatient follow-up to ensure resolution.

Grade II

Antibiotics

Ceftriaxone 2 grams IV once daily, Metronidazole 500 mg IV every 8 hours; continue IV antibiotics for minimum 7 days.


Endoscopic Intervention (ERCP)

Perform within 24-48 hours, therapeutic maneuvers as indicated.


Supportive Care

Aggressive fluid resuscitation, monitoring for sepsis or organ dysfunction.


Monitoring

Close monitoring in a step-down or high-dependency unit.


Follow-Up

Regular outpatient follow-up with imaging to ensure resolution.

Grade III

Antibiotics

Broad-spectrum IV antibiotics, consider vancomycin or meropenem.


ICU Admission

For organ/system dysfunction requiring close monitoring and supportive care.


Endoscopic Intervention (ERCP)

Urgent ERCP, consider PTC if ERCP is not feasible.


Surgical Intervention

For cases where ERCP/PTC is not possible or unsuccessful.


Supportive Care

Hemodynamic support with vasopressors, mechanical ventilation for respiratory failure, renal replacement therapy for acute kidney injury.


Monitoring

Continuous ICU monitoring, regular assessment of organ function and response to treatment.


Follow-Up

Detailed follow-up with specialists post-recovery.

Cholangitis, an infection of the bile ducts, is a critical condition that demands immediate attention and effective management. Here, we delve into the causes, diagnostic criteria, severity grading, and treatment strategies for this potentially life-threatening disease.

What is Cholangitis?

Cholangitis is an inflammation of the bile ducts, usually caused by a bacterial infection. The infection typically ascends from the duodenum and is often associated with bile duct obstruction. The obstructions can result from various factors, including gallstones, biliary strictures, tumors, parasitic infections, and post-surgical complications.

Symptoms of Cholangitis

The clinical presentation of cholangitis includes a range of symptoms:

  • Fever and chills

  • Right upper quadrant abdominal pain

  • Jaundice (yellowing of the skin and eyes)

  • Nausea and vomiting

  • Dark urine and pale stools

  • Pruritus (itching)

Diagnosing Cholangitis: The Tokyo Guidelines

The Tokyo Guidelines provide a systematic approach to diagnosing acute cholangitis, classifying cases into suspected and definite categories based on clinical, laboratory, and imaging findings.

Suspected Acute Cholangitis:

  1. Systemic inflammation:

  • Fever and/or shaking chills

  • Laboratory evidence of an inflammatory response (elevated white blood cell count, C-reactive protein, etc.)

  1. Cholestasis:

  • Jaundice

  • Abnormal liver function tests (elevated ALP, GGT, AST, ALT)

  1. Imaging:

  • Biliary dilatation

  • Evidence of the etiology (e.g., stricture, stone, stent, etc.)

Definite Acute Cholangitis: Diagnosis is confirmed if one item from each of the above categories is present.

Grading the Severity of Cholangitis

The Tokyo Guidelines also offer a severity grading system to guide treatment:

Grade III (Severe): Presence of organ/system dysfunction:

  • Cardiovascular: Hypotension requiring dopamine ≥5 μg/kg per minute, or any dose of norepinephrine

  • Neurological: Disturbance of consciousness

  • Respiratory: PaO2/FiO2 ratio <300

  • Renal: Oliguria, serum creatinine >2.0 mg/dL

  • Hepatic: PT-INR >1.5

  • Hematological: Platelet count <100,000/mm³

Grade II (Moderate): Any two of the following:

  • Abnormal white blood cell count (>12,000 or <4,000/mm³)

  • High fever (≥39°C)

  • Age (≥75 years)

  • Hyperbilirubinemia (total bilirubin ≥5 mg/dL)

  • Hypoalbuminemia (<STD×0.7)

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

Treatment Strategies for Cholangitis

Initial Management:

  • Intravenous antibiotics

  • Fluid resuscitation

  • Correction of electrolyte imbalances

Definitive Management:

  • Endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage

  • Percutaneous transhepatic cholangiography (PTC) if ERCP is not feasible

  • Surgical intervention in refractory or complicated cases


Treatment Strategies for Cholangitis

Initial Management

Definitive Management

Monitoring and Follow-Up

Conclusion for Treatment

Example Order Form

Medication

Dose

Route

Frequency

Administration Instructions

Duration

Ceftriaxone

2 grams

IV

Once daily

Administer over 30-60 minutes

Until further notice or 7 days

Metronidazole

500 mg

IV

Every 8 hours

Administer over 30-60 minutes

Until further notice or 7 days

Treatment Strategies for Cholangitis: Management Based on Severity

Management of cholangitis is stratified based on the severity of the condition, as per the Tokyo Guidelines. Below is a detailed guide to treatment strategies based on severity:

Initial Management for All Patients

  • Intravenous Antibiotics:

  • Ceftriaxone: 2 grams IV once daily

  • Metronidazole: 500 mg IV every 8 hours

  • Fluid Resuscitation: Intravenous crystalloids (e.g., normal saline or lactated Ringer's solution) to maintain hemodynamic stability.

  • Correction of Electrolyte Imbalances: Monitor and correct imbalances as necessary.

Management Based on Severity

Grade I (Mild) Cholangitis

  • Antibiotic Therapy:

  • Continue IV antibiotics until clinical improvement, then switch to oral antibiotics to complete a 7-10 day course.

  • Supportive Care:

  • Hydration, pain management, and antiemetics as needed.

  • Monitoring:

  • Regular monitoring of vital signs, liver function tests, and clinical status.

  • Follow-Up:

  • Outpatient follow-up after discharge to ensure complete resolution.

Grade II (Moderate) Cholangitis

  • Antibiotic Therapy:

  • Continue IV antibiotics for a minimum of 7 days, assess for clinical improvement before considering oral switch.

  • Endoscopic Intervention (ERCP):

  • Perform ERCP within 24-48 hours to achieve biliary drainage.

  • Therapeutic maneuvers such as stone extraction or stent placement as indicated.

  • Supportive Care:

  • Aggressive fluid resuscitation and monitoring for signs of sepsis or organ dysfunction.

  • Monitoring:

  • Close monitoring in a step-down or high-dependency unit as needed.

  • Follow-Up:

  • Regular outpatient follow-up with imaging to ensure the resolution of biliary obstruction.

Grade III (Severe) Cholangitis

  • Antibiotic Therapy:

  • Broad-spectrum IV antibiotics, consider combination therapy with vancomycin or meropenem based on local resistance patterns and severity.

  • Intensive Care Unit (ICU) Admission:

  • For patients with organ/system dysfunction requiring close monitoring and supportive care.

  • Endoscopic Intervention (ERCP):

  • Perform ERCP urgently to relieve biliary obstruction.

  • Consider percutaneous transhepatic cholangiography (PTC) if ERCP is not feasible.

  • Surgical Intervention:

  • Surgical drainage or decompression in cases where ERCP/PTC is not possible or unsuccessful.

  • Supportive Care:

  • Hemodynamic support with vasopressors if needed.

  • Mechanical ventilation for respiratory failure.

  • Renal replacement therapy for acute kidney injury.

  • Monitoring:

  • Continuous monitoring in the ICU with regular assessment of organ function and response to treatment.

  • Follow-Up:

  • Detailed follow-up with specialists in gastroenterology and surgery post-recovery.

Conclusion

Cholangitis is a serious medical condition that requires prompt diagnosis and treatment. Utilizing the Tokyo Guidelines for diagnosis and severity grading ensures a systematic approach to managing this potentially fatal disease. Timely and appropriate treatment can prevent complications such as sepsis, liver abscess, and chronic liver disease.

Stay updated on the latest guidelines and advancements in the management of cholangitis to provide the best care for your patients. For more in-depth information on cholangitis and other medical conditions, stay tuned to our blog.


7 views1 comment

Recent Posts

See All

1 Comment


Mayta
Mayta
May 26

Charcot's triad consists of fever, RUQ pain, and jaundice. It is reported in up to 50-70% of patients with cholangitis.

Like
Post: Blog2_Post
bottom of page