Guideline sources The following summarized guidelines for the evaluation and management of acute cholangitis are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2015), the American College of Radiology (ACR 2019), the Tokyo Guidelines (TG 2018), and the European Association for the Study of the Liver (EASL 2016). 1 2 3 4 5 Calculator CholeS score for duration of lap Guidelines 1. Diagnostic investigations Clinical evaluation: https://web.pathway.md/diseases/recAlaNWnZiNz808n 1/7 6/23/23, 1:38 AM Acute cholangitis Pathway Elicit medical history and perform physical examination to identify the characteristic symptoms of gallbladder stones, such as episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics. B Evaluate for common bile duct stones in patients with jaundice, acute cholangitis, or acute pancreatitis. A Laboratory tests: Obtain the following tests as part of the initial evaluation of patients with fever, chills, abdominal pain and/or jaundice: WBCs CRP liver biochemical tests. B Obtain liver biochemical tests in patients with suspected common bile duct stones. B Abdominal ultrasound: obtain abdominal ultrasound as the initial investigation in patients with fever, chills, abdominal pain and/or jaundice. B Show 4 more Endoscopic retrograde cholangiopancreatography: As per ASGE 2021 guidelines: Consider performing ERCP over percutaneous transhepatic biliary drainage in patients with cholangitis. C Consider performing ERCP within 48 hours after admission. C As per EASL 2016 guidelines, perform ERCP with sphincterotomy and stone extraction in patients with biliary pancreatitis with suspected coexistent acute cholangitis, with timing depending on the severity of cholangitis but preferably within 24 hours. A Show 2 more As per ASGE 2015 guidelines, perform ERCP in patients with acute biliary pancreatitis with concomitant cholangitis or biliary obstruction. A Show 2 more Magnetic resonance cholangiopancreatography: consider obtaining MRCP in case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound. C Show 4 more Endoscopic ultrasound: consider obtaining EUS in case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound. C Show 3 more 2. Medical management Antibiotics: As per TG 2018 guidelines: https://web.pathway.md/diseases/recAlaNWnZiNz808n 2/7 6/23/23, 1:38 AM Acute cholangitis Pathway Administer antibiotics for 4-7 days in patients with acute cholangitis, once the source of infection is controlled. B Administer antibiotics according to the following regimens in patients with cholangitis: Situation Guidance Penicillins - do not use ampicillin + sulbactam if the resistance rate is > 20% Grade 1 Cephalosporins - cefazolin/cefotiam/cefuroxime/ceftriaxone/c efotaxime +/- metronidazole, cefmetazole, cefoxitin, flomoxef, cefoperazone + sulbactam Carbapenems - ertapenem Fluoroquinolones - ciprofloxacin/levofloxacin/pazufloxacin +/- metronidazole, moxifloxacin Penicillins - piperacillin + tazobactam Grade 2 Cephalosporins - ceftriaxone/cefotaxime/cefepime/cefozopra n/ceftazidime with or without metronidazole, cefoperazone + sulbactam Carbapenems - ertapenem Fluoroquinolones - ciprofloxacin/levofloxacin/pazufloxacin +/- metronidazole, moxifloxacin Penicillins - piperacillin + tazobactam Grade 3 Cephalosporins - cefepime/ceftazidime/cefozopran +/- metronidazole Carbapenems - imipenem + cilastatin, meropenem, doripenem, ertapenem Monobactams - aztreonam +/- metronidazole Penicillins - piperacillin + tazobactam Healthcare-associated cholangitis Cephalosporins - cefepime/ceftazidime/cefozopran +/- metronidazole Carbapenems - imipenem/cilastatin, meropenem, doripenem, ertapenem https://web.pathway.md/diseases/recAlaNWnZiNz808n 3/7 6/23/23, 1:38 AM Acute cholangitis Pathway Monobactams - aztreonam +/- metronidazole. B As per EASL 2016 guidelines, administer immediate broad-spectrum antibiotics in patients with cholangitis. B Spasmolytics and opioids: Consider administering spasmolytics (such as butylscopolamine) for the management of symptomatic patients with gallstones. B Consider administering opioids for the management of severe symptoms in patients with gallstones. B Nonsteroidal anti-inflammatory drugs: administer NSAIDs (such as diclofenac or indomethacin) for the management of patients with biliary colic. B 3. Therapeutic procedures Biliary decompression: As per ACR 2019 guidelines, place an endoscopic internal biliary catheter with a removable plastic stent or a percutaneous internal/external biliary catheter as the initial therapeutic procedure in patients with dilated bile ducts and suspected biliary sepsis or acute cholangitis. Decide between procedures depending on the patient's anatomy and availability of resources and institutional preferences. B As per EASL 2016 guidelines, perform biliary decompression for the management of patients with cholangitis. B Show 3 more Endoscopic sphincterotomy: perform endoscopic sphincterotomy and stone extraction for the management of patients with bile duct stones. B . Obtain intraoperative ERCP or laparoscopic bile duct exploration in combination with cholecystectomy as alternatives if adequate expertise is available. B Show 2 more Percutaneous or endoscopic biliary drainage: consider performing percutaneous or balloon endoscopy-assisted treatment of bile duct stones in patients with altered anatomy, such as previous Roux-en-Y anastomosis or bariatric surgery. C Litholysis and lithotripsy: Avoid offering litholysis with bile acids alone or in combination with extracorporeal shock wave as first-line treatment for gallbladder stones. D Consider offering extracorporeal shock wave, electrohydraulic or laser lithotripsy in patients failed standard stone extraction procedures. C 4. Perioperative care https://web.pathway.md/diseases/recAlaNWnZiNz808n 4/7 6/23/23, 1:38 AM Acute cholangitis Pathway Preoperative evaluation: Avoid obtaining routine preoperative tests other than abdominal ultrasound to confirm the presence of gallstones in patients planned to undergo cholecystectomy. D Consider obtaining liver biochemical tests before elective cholecystectomy in individually selected patients. C Intraoperative cholangiography: avoid obtaining routine or selective intraoperative cholangiography during cholecystectomy in patients at low risk of common bile duct stones. D Postoperative evaluation: consider obtaining EUS or MRCP in the diagnostic evaluation of patients with biliary symptoms after cholecystectomy. C 5. Surgical interventions Indications for cholecystectomy (symptomatic stones): perform cholecystectomy as the preferred option for treatment of patients with symptomatic gallbladder stones. B Indications for cholecystectomy (concomitant abdominal surgery): Avoid performing routine cholecystectomy in patients with asymptomatic stones during abdominal surgery for other indications, including bariatric surgery, as well as kidney, lung or pancreas transplantation. D Defer cholecystectomy whenever possible in patients in the early phase after heart or lung transplantation with symptomatic gallbladder stones. B Indications for cholecystectomy (acute biliary pancreatitis): perform cholecystectomy during the index hospital admission in patients with mild acute biliary pancreatitis. A Indications for cholecystectomy (bile duct stones): Perform cholecystectomy combined with bile duct exploration or intraoperative ERCP in patients with bile duct stones failed endoscopic therapy. B Consider preferring primary closure over T-tube drainage in low risk cases, in the event of surgical bile duct exploration. C Choice of surgical approach: perform laparoscopic cholecystectomy as the preferred surgical modality in patients with symptomatic gallbladder stones, including acute calculous cholecystitis A and Child-Pugh A or B liver cirrhosis. B Show 3 more Timing for cholecystectomy: perform cholecystectomy as early as possible in patients with uncomplicated biliary colic. B Show 3 more Intraoperative management of bile duct stones: consider performing bile duct exploration, transcystic stone extraction or endoscopic clearance as alternative treatment options in case of intraoperative detection of bile duct stones. C Intraoperative management of bile duct injuries: consider performing primary surgical repair of intraoperatively recognized bile duct lesions A, B or C, if surgical expertise is available. C https://web.pathway.md/diseases/recAlaNWnZiNz808n 5/7 6/23/23, 1:38 AM Acute cholangitis Pathway Show 3 more 6. Specific circumstances Asymptomatic patients: avoid offering routine treatment in patients with asymptomatic gallbladder stones. D Show 2 more Elderly patients: Perform cholecystectomy as soon as the patient is deemed fit for surgery in the elderly and in patients with high anesthetic risk with gallstone complications (such as acute cholecystitis, gallstone pancreatitis, or obstructive jaundice). B Do not withhold laparoscopic cholecystectomy solely based on the chronological age of the patient. D Pregnant patients: recognize that the use of radiographs is not contraindicated during pregnancy provided care is taken to minimize radiation exposure. B Show 3 more 7. Preventative measures Lifestyle modifications: advise healthy lifestyle and food, regular physical activity and maintenance of an ideal body weight to prevent cholesterol gallbladder stones and symptomatic gallstones. B Ursodeoxycholic acid: avoid offering pharmacological agents for the prevention of gallstones in general population. D Show 2 more Prophylactic cholecystectomy: Consider performing cholecystectomy in patients with hereditary spherocytosis or sickle cell disease with asymptomatic gallstones undergoing splenectomy or other abdominal surgery. C Avoid performing routine prophylactic cholecystectomy during bariatric surgery. D Measures with no evidence for benefit: insufficient evidence to recommend any pharmacological agent for the prevention of recurrent bile duct stones. I Show 2 more References 1. EASL. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016 Jul;65 1 146 181. Open 2. Expert Panel on Interventional Radiology:, Alexandra H Fairchild, Eric J Hohenwalter et al. ACR Appropriateness Criteria Radiologic Management of Biliary Obstruction. J Am Coll Radiol. 2019 https://web.pathway.md/diseases/recAlaNWnZiNz808n 6/7 6/23/23, 1:38 AM Acute cholangitis Pathway May;16 5S S196 S213. Open 3. James L Buxbaum, Carlos Buitrago, Alice Lee et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021 Aug;94 2 207 221.e14. Open 4. Harumi Gomi, Joseph S Solomkin, David Schlossberg et al. Tokyo Guidelines 2018 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 3 16. Open 5. ASGE Standards of Practice Committee, Krishnavel V Chathadi, Vinay Chandrasekhara et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015 Apr;81 4 795 803. Open 6. Manes G, Paspatis G, Aabakken L et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy ESGE guideline. Endoscopy. 2019 May;51 5 472 491. Open 7. Society of American Gastrointestinal and Endoscopic Surgeons. Choosing Wisely SAGES recommendations. Choosing Wisely. 2019. Open 8. Miura F, Okamoto K, Takada T et al. Tokyo Guidelines 2018 initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 31 40. Open 9. Tadahiro Takada. Tokyo Guidelines 2018 updated Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 1 2. Open 10. Shuntaro Mukai, Takao Itoi, Todd H Baron et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci. 2017 Oct;24 10 537 549. Open 11. Susumu Tazuma, Michiaki Unno, Yoshinori Igarashi et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017 Mar;52 3 276 300. Open 12. Expert Panel on Gastrointestinal Imaging:, Christine M Peterson, Michelle M McNamara et al. ACR Appropriateness Criteria Right Upper Quadrant Pain. J Am Coll Radiol. 2019 May;16 5S S235 S243. Open 13. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open https://web.pathway.md/diseases/recAlaNWnZiNz808n 7/7