The classic presentation of acute cholangitis is fever, abdominal pain, and jaundice (Charcot's triad), though only 50 to 75 percent of patients with acute cholangitis have all three findings. Confusion and hypotension can occur in patients with suppurative cholangitis, producing Reynolds pentad, which is associated with significant morbidity and mortality. If septic shock develops, multiorgan failure may be seen. Hypotension may be the only presenting symptom in elderly patients or those on glucocorticoids.
Acute cholangitis should be suspected if a patient has one of the following
•Fever and/or shaking chills
•Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation)
and one of the following:
•Abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, aspartate aminotransferase)
The diagnosis is considered definite if, in addition to meeting the criteria for a suspected diagnosis, the patient also has:
•Biliary dilation on imaging
•Evidence of an etiology on imaging (eg, a stricture, stone, or stent).
Management of acute cholangitis includes all of the following: monitoring for and treating sepsis, providing antibiotic coverage, and establishing biliary drainage.
Patients with acute cholangitis should receive empiric therapy with antibiotics that cover colonic bacteria. Once blood culture results are available, therapy should be tailored.
We recommend endoscopic sphincterotomy with stone extraction and/or stent insertion for establishing biliary drainage in acute cholangitis rather than treatment with antibiotics alone (Grade 1B). Common bile duct stones can be removed successfully in 90 to 95 percent of patients after sphincterotomy. If ERCP is not technically feasible or fails to establish biliary drainage, biliary drainage can often be achieved by percutaneous transhepatic cholangiography or open surgical decompression.
Seventy to 80 percent of patients with acute cholangitis will respond to conservative management with antibiotic therapy. Patients should undergo biliary drainage as soon as possible, but if they respond to antibiotics, it is reasonable to wait until arrangements can be made to perform an ERCP in the endoscopy suite with a full complement of experienced staff, provided the procedure can be done within 24 to 48 hours． If ERCP is delayed and the patient has not improved over the first 24 hours with conservative management, urgent biliary decompression is required.
Urgent biliary decompression is also indicated for patients with signs of acute suppurative cholangitis, such as:
•Persistent abdominal pain
•Hypotension despite adequate resuscitation
•Fever greater than 39°C (102°F)
•Mental confusion (a predictor of poor outcome)