Management of Acute Cholangitis and Cholecystitis

Diagnosis and Severity Assessment

The Tokyo Guidelines 2018 classify acute cholangitis into three grades, with Grade I being mild, Grade II moderate, and Grade III severe, based on the presence of organ dysfunction 1, 2
For acute cholecystitis, the guidelines also classify it into three grades, with Grade I being mild, Grade II moderate, and Grade III severe 1, 2

Empiric broad-spectrum antibiotics should be started promptly, with options including piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam, and the duration of therapy should be at least 4 days after successful biliary drainage, or up to 2 weeks if Enterococcus or Streptococcus is present 2, 3
Early biliary drainage is recommended for moderate to severe cholangitis, with endoscopic retrograde cholangiography (ERC) being the preferred method 1, 2
For acute cholecystitis, early laparoscopic cholecystectomy is recommended for patients with mild disease and a Charlson comorbidity index (CCI) ≤5 and ASA-PS ≤2, while medical treatment and/or gallbladder drainage may be considered for those with moderate or severe disease 1, 2

Laboratory tests, including liver function tests and inflammatory markers such as CRP, PCT, and lactate levels, can help evaluate the severity of acute cholangitis and cholecystitis 3
Imaging studies, including abdominal triphasic CT and CE-MRCP, can help visualize the biliary ducts and detect any injuries or obstructions 3
EUS and MRCP have high sensitivity and specificity for detecting common bile duct stones 2

Failure to initiate early antibiotic therapy in suspected cholangitis can lead to increased mortality, and bile cultures should be obtained during drainage procedures to guide antibiotic therapy 1, 2
Delay in biliary drainage for moderate to severe cholangitis worsens outcomes, and the presence of residual stones or ongoing biliary obstruction requires extended antimicrobial treatment 2

The World Journal of Emergency Surgery recommends that the duration of empiric broad-spectrum antibiotics should be at least 4 days after successful biliary drainage, and treatment must be extended to 2 weeks if Enterococcus or Streptococcus is present to prevent infectious endocarditis 4

Early laparoscopic common bile duct exploration (LCBDE) is suitable for mild and moderate acute cholangitis, but should be avoided in severe acute cholangitis due to high mortality rates, particularly in patients over 80 years old 5, 6, 7
Early LCBDE (within 72 hours) versus delayed LCBDE showed no significant difference in complication rates for mild-moderate disease 5, 6
LCBDE has comparable stone clearance rates to endoscopic approaches (91.7% vs 88.1%) 6
LCBDE offers shorter hospital stays and lower recurrence rates (2.06% vs 9.47%) compared to ERCP + LC 6, 7

Attempting early LCBDE in severe cholangitis, especially in elderly patients (>80 years), carries unacceptable mortality risk 5, 6, 7
Performing laparoscopic cholecystectomy after ERCP is more difficult due to severe adhesions (33.4% of cases) and inflammation around Calot's triangle 6, 7
ERCP-induced sphincter dysfunction causes permanent damage and increases CBD stone recurrence rates 6, 7