Ascending Cholangitis 101

Today at Parkland Morning Report we talked about the diagnosis and management of ascending cholangitis. Below is a summary of cholangitis from last week’s Potpourri. Check it out!

  • Frequently polymicrobial from gastrointestinal flora including E. coli, Klebsiella, Enterobacter, Enterococcus, Anaerobes
  • Pathogenic role of enterococci and anaerobes is not well defined
  • Results from bacterial infection in the setting of an obstructed biliary tree
  • Sources of obstruction include gallstones, strictures, biliary or pancreatic malignancy, iatrogenic from occluded stent or drain
  • Charcot Triad: fever, jaundice, and RUQ pain (all three present in <50% of cases)
  • Reynold’s pentad: Charcot’s triad + altered mental status and hypotension and is associated with increased morbidity and mortality
  • Diagnosis often made clinically but requires imaging confirmation
    • Ultrasound: recommended first imaging technique but if normal does not rule out cholangitis
    • MRCP: increasingly utilized in suspected malignancy and diagnosis of duct stones
    • ERCP: should not be used soley for diagnostic purposes due to its risk; best utilized when likelihood of intervention is high

    Management: Early ERCP should be considered in conjunction with abx therapy

    Mild-moderate disease: Ertapenem; fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin); cephalosporins; can add Flagyl for anaerobic coverage

    Severe disease: Piperacillin/tazobacatam; cephalosporin +/- Flagyl; Imipenem or Meropenem or Doripenem

    Consider adding vancomycin for health care-associated biliary infections of any severity