7/10/2015 Acute Cholangitis Treatment & Management: Prehospital Care, Emergency Department Care, Consultations

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Acute Cholangitis Treatment & ManagementAuthor: Timothy M Scott, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...

Updated: Nov 10, 2014

Prehospital CareDiagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice,and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous(IV) line.

In unstable patients with cholangitis, prehospital care should include the following:

Immediate assessment of ABCsMonitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucosemeasurement)Stabilization (eg, oxygen, placement of 2 largebore IVs, administration of IV fluids to unstable patients)Rapid transport

Emergency Department CareSuspect mild cholangitis in patients with jaundice and a fever; consider cholangitis in all patients with sepsis.

The degree of urgency of treatment depends on severity of illness. Important points are resuscitation, diagnosis,and treatment.

Management of acute cholangitis in the emergency department includes the following:

After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasalcanula, and obtain an ECG. Draw and send laboratory studies (including blood cultures) when theintravenous line is placed.Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration ofantibiotics if blood cultures cannot be drawn.Correct any electrolyte abnormalities or coagulopathies.For management of patients in septic shock, see Shock, Septic.Standard therapy for cholangitis consists of broadspectrum antibiotics with close observation to determinethe need for emergency decompression of the biliary tree.A nasogastric tube may be helpful for patients who are vomiting.Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.

The surgical literature states that, in patients with mild cholangitis, 8090% respond to medical therapy.[3]Approximately 15% do not respond and subsequently require immediate surgical or endoscopic decompression.Mortality rates approach 100% for patients who fail medical therapy and do not have surgical decompression.

In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness.In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist inaddition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality ratesfrom 30% to 10%.

Medical therapy can be complementary to surgical or endoscopic treatments. In less ill patients, medical treatmentmay be all that is necessary. Perform the following:

Maintain medical therapy and consider elective surgery with patients who show improvement. Patients whoare being medically managed and do not improve or who deteriorate should rapidly be referred to undergoeither ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below.

Algorithm for management of patients with acute cholangitis.

The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage. A study bySharma showed equal safety and effectiveness when using a 7 Fr stent or 10 Fr stent for biliary drainage inpatients with severe cholangitis. [10]

A novel technique that is being used in Asia in the surgical management of acute cholangitis is endoscopicnasobiliary drainage.[11]

ConsultationsImmediately consult a surgeon and a gastroenterologist.

Although most patients respond to antibiotics and conservative care, a subset requires emergent procedures (eg,

7/10/2015 Acute Cholangitis Treatment & Management: Prehospital Care, Emergency Department Care, Consultations

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ERCP, percutaneous drainage). In deciding to drain, consult with a gastroenterologist and a surgeon.

Increased mortality is observed in patients with hypotension, acute renal failure, liver abscess, cirrhosis, highmalignant strictures, female gender, and advanced age. Therefore, consider decompression earlier for thesepatients. Patients with malignant obstruction usually do not respond to antibiotics (59% compared to 85%).

Unstable septic patients require clinical judgment to determine if they will survive until medical therapy has a chanceto work or if they require emergency decompression with its associated high mortality rate.

Contributor Information and DisclosuresAuthorTimothy M Scott, DO Chief Resident, Department of Emergency Medicine, Detroit Medical Center, WayneState University School of Medicine

Timothy M Scott, DO is a member of the following medical societies: American College of EmergencyPhysicians, American Medical Association, American Osteopathic Association, Emergency MedicineResidents' Association

Disclosure: Nothing to disclose.

Coauthor(s)Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department ofEmergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine,American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor BoardFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment.

Chief EditorBarry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine,Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western ReserveUniversity School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha,American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy ofMedicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy ofEmergency Medicine, American College of Chest Physicians, American College of Emergency Physicians,American College of Physicians

Disclosure: Nothing to disclose.

AcknowledgementsEugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of EmergencyMedicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine,Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Jeffrey A Manko, MD A ssistant Professor of Emergency Medicine, Director, Emergency Medicine ResidencyProgram, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center

Jeffrey A Manko, MD is a member of the following medical societies: American College of EmergencyPhysicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sally Santen, MD Program Director, Assistant Professor, Department of Emergency Medicine, VanderbiltUniversity

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physiciansand Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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