Cholangitis: Treatment

From: http://emedicine.medscape.com/article/774245-treatment

Suspect mild cholangitis in patients with jaundice and a fever; consider cholangitis in all patients with sepsis.
Degree of urgency of treatment depends on severity of illness. Important points are resuscitation, diagnosis, and treatment.
After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG. Draw and send laboratory studies (including blood cultures) when the intravenous 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 of antibiotics 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 broad-spectrum antibiotics with close observation to determine the 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, 80-90% 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 in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
Medical therapy can be complementary to surgical or endoscopic treatments. In less ill patients, medical treatment may be all that is necessary.
Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage. See the management algorithm below.

The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage. A study by Sharma showed equal safety and effectiveness when using a 7 Fr stent or 10 Fr stent for biliary drainage in patients with severe cholangitis.8
A novel technique that is being used in Asia in the surgical management of acute cholangitis is endoscopic nasobiliary drainage.9
Consultations
Immediately consult a surgeon and a gastroenterologist.
While most patients respond to antibiotics and conservative care, a subset requires emergent procedures (eg, 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, high malignant strictures, female gender, and advanced age. Therefore, consider decompression earlier for these patients. 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 chance to work or if they require emergency decompression with its associated high mortality rate.