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Journal of Visceral Surgery (2019) xxx, xxx—xxx

Available online at

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www.sciencedirect.com

REVIEW

Acute cholangitis: Diagnosis and

management
A. Sokal a, A. Sauvanet b, B. Fantin a,c,
V. de Lastours a,c,∗

a
Internal medicine unit, hôpital Beaujon, Assistance—publique des Hôpitaux de Paris, 92110
Clichy, France
b
Hepatic and pancreatic surgery unit, digestive disease center, hôpital Beaujon,
Assistance—publique des Hôpitaux de Paris, 92110 Clichy, France
c
Inserm, IAME, UMR 1137, université Paris Diderot, 75018 Paris, France

KEYWORDS Summary Acute cholangitis is an infection of the bile and biliary tract which in most cases
Acute cholangitis; is the consequence of biliary tract obstruction. The two main causes are choledocholithiasis
Etiology; and neoplasia. Clinical diagnosis relies on Charcot’s triad (pain, fever, jaundice) but the insuf-
Epidemiology; ficient sensitivity of the latter led to the introduction in 2007 of a new score validated by the
Management Tokyo Guidelines, which includes biological and radiological data. In case of clinical suspicion,
abdominal ultrasound quickly explores the biliary tract, but its diagnostic capacities are poor,
especially in case of non-gallstone obstruction, as opposed to magnetic resonance cholangiopan-
creatography and endoscopic ultrasound, of which the diagnostic capacities are excellent. CT
scan is more widely available, with intermediate diagnostic capacities. Bacteriological sampling
through blood cultures (positive in 40% of cases) and bile cultures is essential. A wide variety
of bacteria are involved, but the main pathogens having been found are Escherichia coli and
Klebsiella spp., justifying first-line antimicrobial therapy by a third-generation cephalosporin.
Systematic coverage of Enterococcus spp. and anaerobic infections remains debated, and is
usually recommended, in case of severity criteria for Enterococcus severity levels, or anaero-
bic bilio-digestive anastomosis for anaerobes. Presence of a biliary stent is the only identified
risk-factor associated with infections by multidrug-resistant pathogens. Along with antimicro-
bial therapy, endoscopic or radiological biliary drainage is a crucial management component.
Despite improved management, mortality in cases of acute cholangitis remains approximately
5%.
© 2019 Published by Elsevier Masson SAS.

Introduction biliary duct infection. Its first known description was given
in 1877 by Jean Martin Charcot (1825—1893) in his ‘‘Lesson
Acute cholangitis or angiocholitis (from the Greek angeion: on diseases of the liver, biliary tract and kidneys’’ at
vessels and kholé: bile) is a potentially severe bile and the Paris faculty of medicine [1]. In the 18th lesson ‘‘Of
symptomatic hepatic fever — Comparison with urosepsis
fever’’, he described an association of intermittent hepatic
∗ Corresponding author. Service de médecine interne, hôpital fever with icterus and biliary colic, which was to become
the well-known eponymous triad: pain-fever-jaundice. In
Beaujon, AP—HP, 100, boulevard Général Leclerc, 92110 Clichy,
France. our times, this triad remains essential to clinical diagno-
E-mail address: [email protected] (V. de Lastours). sis, but is confirmed more often than not, by biological,

https://doi.org/10.1016/j.jviscsurg.2019.05.007
1878-7886/© 2019 Published by Elsevier Masson SAS.

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microbiological and radiological data. In this review, we

Table 1 Etiologies of acute cholangitis.
shall discuss the respective role of each of these, while
bearing in mind that according to the Tokyo Guidelines, the Etiologies Frequency References
gold standard for diagnosis of acute cholangitis consists in: Biliary lithiases 28—70% [6,11]
observation of purulent bile; clinical remission following Malignant stenoses 10—57% [6,11,12]
bile duct drainage; remission achieved by antimicrobial Pancreatic cancer
therapy alone, in patients in whom the only site of infection Cholangiocarcinoma
was the biliary tree [2,3]. Gall bladder adenocarcinoma
In addition to diagnosis, treatment of acute cholangitis Tumor of the bilio-pancreatic
remains a major medical issue. Points of interest include ampulla
management of patients with comorbidities, severity assess- Duodenal tumors
ment, evolution of the implicated pathogens influencing the Hepatic metastases
choice of probabilistic antimicrobial therapy (degree of cov- Adenopathy
erage against multidrug-resistant bacteria [MRB], anaerobic Others (other bile duct
infections, enterococci. . .), duration of antibiotic treatment tumors, extrinsic
and timing of bile duct drainage. The cruciality of bile compressions. . .)
duct obsruction management bears mentioning; while endo- Benign stenoses 4—28% [6]
scopic procedures have yielded undeniable improvement, Post-surgical (including
the respective roles of echo-endoscopy have yet to be cholecystectomy)
clearly defined. Acute or chronic pancreatitis
Since 2007, a group of experts from throughout the world Primary sclerosing cholangitis
has been working together in view of proposing recommen- Other autoimmune disorders
dations for diagnosis and treatment of acute cholangitis: (including cholangitis
the Tokyo Guidelines, which were updated in 2013 and most associated with IgG4)
recently in 2018 [4]. Complicated lithiasis (Mirizzi
This article proposes a review of recent developments syndrome)
incorporating the main points of interest stemming from the Congenital abnormalities
Tokyo Guidelines. (including Caroli disease)
Parasitoses 0—24% [10]
Ascaris lumbricoides
Pathophysiology and etiologies of acute Clonorchis sinensis
cholangitis Fasciola hepatica
Opisthorchis felineus
Two central phenomena explain the pathophysiology of Opisthorchis viverrini
acute cholangitis. The first is obstruction of the biliary tract Echinococcus granulosus
by an obstacle, leading to stoppage of enterohepatic circu- Echinococcus multilocularis
lation of bile and increased intraductal pressure, which is Taenia Saginata
responsible for altered biliary secretion and brings about Others
bilio-venous and bilio-lymphatic reflux [5,6]. The second Duodenal diverticulum
consists in bacterial proliferation in bile, which is normally (Lemmel syndrome)
sterile, even though some colonization has been observed in Haemobilia
persons without biliary tract infection. There are two possi- Sump syndrome, reflux,
ble sources of contamination: ascendant (duodenal flora) or surgical clip migration and
hematogenous (portal venous blood) [7]. Heightened intra- other post-surgical causes
ductal pressure subsequently leads to bilio-venous bacterial Obstruction or migration of
translocation. It bears mentioning that by definition, reflux biliary stent
cholangitis is the exception inasmuch as it is secondary not Fungal balls (fungal masses)
to biliary tract obstruction, but rather to food debris reflux, Oriental cholangitis
a source of transitory obstruction that is considerably more Retroscopic post-
difficult to highlight (Fig. 1). cholangiopancreatography
The multiple etiologies of acute cholangitis are presented with endoscopic approach
as exhaustively as possible in des Table 1, which supple- Amyloses (digestive AL
ments the table put forward by Mosler [8] and Carpenter amyloidosis)
[9] and schematized in Fig. 2 (according to [9,10]). Given Vascular compression
for information purposes only, the reported frequencies of (cavernoma, aneurysms)
occurrence should be interpreted cautiously insofar as they Medical (ceftriaxone,
may vary considerably from one center to another accord- carbamazepine)
ing to patient recruitment and series duration. While the
most recent and robust multicenter epidemiological data
(more than 6000 acute cholangitis episodes) date from 2017,
they originated in Japanese and Taiwanese centers [11]. sclerosing cholangitis and ascending cholangitis following
And while lithiasis of the common bile duct represents instrumentation of the biliary duct (0.5 to 2.4% of endo-
the main etiology of acute cholangitis, other causes are scopic retrograde cholangiopancreatography cases [ERCP])
tending to become more and more frequent; they include [13]. Lastly, in patients with a biliary prosthesis, occlusion
neoplasia (especially in patients over 50 years of age, pos- of the latter occurs in half of cases with a plastic prosthesis
sibly becoming the predominant etiology) [12], primary and in a quarter of cases in patients with self-expandable

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Acute cholangitis: Diagnosis and management 3

Figure 1. Proposition for treatment and management of acute cholangitis in accordance with the pathophysiological mechanism.

metal prostheses, putting them at high risk of cholangitis [24]. Reflux is likely to consist in food debris and may
[14]. possibly be objectified by imaging (one example: con-
Asymptomatic gallstones (vesicular lithiasis) is frequent trast radiography of the upper gastrointestinal transit
(around 10% of the population in Europe [15]), but cholangi- in choledocoduodenal anastomosis) or scintigraphy (one
tis occurrence seems exceptional in asymptomatic patients example: biliary scintigraphy after cephalic duodenopancre-
and has relatively seldom been studied. As regards the few atectomy). In this context, repeated cholangitis episodes
publications concerning patients with initially asymptomatic should instigate search for a contributing factor such as
gallstones, not a single cholangitis episode was reported in anastomotic stenosis or an impediment to digestion beneath
three large-scale cohorts (at least 100 patients having been the anastomosis [23,24].
monitored for at least 10 years) [16—18]. In two other cohort
studies, only one cholangitis episode was reported among Acute cholangitis diagnosis
739 and 135 patients respectively [19,20], while in a third
study four cases involving cholangitis were reported among
123 patients monitored for 20 years, but they went by dif- Clinical diagnosis of acute cholangitis is classically based in
ferent names (‘‘angiocholitis’’ and ‘‘obstructive icterus’’) the Charcot triad (pain, fever, jaundice). However, its excel-
[21]. On the basis of other, less recent data, the authors of lent specificity (96%) is counteracted by its poor sensitivity
the Tokyo Guidelines (TG) 2013 found an incidence of 0.3% (26%) [6]. In fact, association of the three symptoms may be
to 1.6% of acute cholangitis in biliary lithiasis patients [2]. present in only 22% of cholangitis patients [25]. While the
One particular case is reflux cholangitis, which com- most frequent symptoms are fever and abdominal pain (up
plicates approximately 10% of bilio-digestive anastomoses to 80% of patients), abdominal pain may be absent in half of
whatever the indication: bile duct stones [22], postopera- elderly subjects [26], and jaundice is present in 60 to 70%
tive stenosis repair [23] or cephalic duodenopancreatectomy of patients.

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Figure 2. Schema for the main causes of acute cholangitis. Original schema drawn from [9]. PSC: Primary sclerosing cholangitis.

In 2007, a multidisciplinary meeting of international three degrees of severity are associated with increasing
experts took place in Tokyo and published their initial mortality, from 1.2% for grade 1 to 2.6% for grade 2 and
recommendations (Tokyo Guidelines=TG), which were sub- more than 5% for grade 3 [2,4,28]. It should nonetheless be
sequently updated in 2013 and 2018. In TG 2007, a new noted that correlation between severity as measured by the
diagnostic score introducing biological and radiological data score is less than perfect, particularly in patients suffering
was proposed and yielded improved but still insufficient sen- from cholangitis secondary to neoplasia, biliary prosthesis
sitivity and specificity scores (83% and 80% respectively) [3]. obstruction, or intrahepatic obstruction [28,29]; moreover,
The score was revised in 2013 and maintained in 2018 [27], the score often tends to underestimate severity. Procalci-
it is presented in Table 2. In diagnosis of acute cholangitis, tonin could constitute an interesting marker for severity
it presents sensitivity and specificity scores of 92% and 78% (sensitivity at 97% and specificity at 73% for diagnosis of
respectively. The revised score no longer includes abdominal severe acute cholangitis) [30].
pain, which is not sufficiently specific.

Imaging
Severity criteria
Highlighting biliary tract dilatation or an obstacle in
In view of predicting the severity of an episode of acute the biliary tract is a key diagnostic element. Several
cholangitis, in 2013 the TG experts drew up a scoring sys- imagery modalities may be envisioned: abdominal ultra-
tem, presented in Table 3, which was not modified in 2018. sound, abdominal CT, MRI and echo-endoscopy (EE), coupled
Three groups are classified according to severity; the illness or not with ERCP. As biliary tract dilatation is relatively sim-
is categorized as grade 1, non-severe, if none of the fol- ple to visualize, they may be inadequate in the event of
lowing serious symptoms are present: fever > 39 ◦ C, age > 75 acute obstruction. Moreover, according to a Cochrane meta-
years, hyperleukocytosis >12G/L, bilirubinemia > 85 ␮mol/L analysis (to be interpreted with caution insofar as it is based
or hypoalbuminemia < 0.7 × the lower limit of the normal on non-recent series, with pronouncedly variable results),
range. Grade 3 is reached in the event of organ failure, ultrasound manifests low sensitivity (73%) in detection of
while a patient is considered as grade 2 or intermediate common bile duct stone [31]. And as regards obstacles other
when at least two of the above-mentioned serious symp- than choledocholithiasis, its performances have been even
toms are present, but no organ failure has occurred. The less impressive. To sum up, normal abdominal ultrasound

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Acute cholangitis: Diagnosis and management 5

Table 2 TG2013/2018 diagnostic criteria. Table 4 Micro-organisms responsible for acute

Criteria Threshold cholangitis.
Germ Hemoculture Biliary
A-Systemic
(%) cultures (%)
inflammation
A-1 Fever or chills > 38 ◦ C Gram negative bacilli
A-2 Biological Leukocytes < 4 Escherichia coli 35—62 31—44
inflammatory or > 10G/L Klebsiella spp. 12—28 9—20
syndrome CRP≥10 mg/L Pseudomonas spp. 4—14 0.5—19
B-Cholestasis Enterobacter spp. 2—7 5—9
B-1 Icterus/jaundice Total biliru- Citrobacter spp. 2—6
bin ≥ 34 ␮mol/L Acinetobacter spp. 3
B-2 Abnormal liver ASAT, ALAT, Gram-positive cocci
function test PAL and Enterococcus spp. 10—23 3—34
gamma- Streptococcus spp. 6—9 2—10
GT > 1.5 × ULN Staphylococcus spp. 2 0
C-Imagery Anaerobia 1 4—20
C-1 Bile duct Others 17
dilatation
Adapted from Tokyo Guidelines 2018.
C-2 Imagery
providing proof of
etiology does not rule out an acute cholangitis and other examina-
Suspected diagnosis One item in tions must be proposed.
A + one item in Abdominal and pelvic CT with and without injection
B or C presents several advantages; it is more sensitive and spe-
Certain diagnosis One item in A, cific than ultrasound (a score proposed in 2012 presents
B and C sensitivity >83% and specificity approximating 83% in acute
cholangitis diagnosis, whatever the cause) [32]; moreover, it
CRP: C reactive protein; ASAT: aspartate aminotransferase;
facilitates search for complications (hepatic abscess, portal
ALAT: alanine aminotransferase; ULN: upper limit of normal.
thrombosis. . .) and excludes alternative etiologies of abdom-
inal pain. Bilio-pancreatic MRI represents the non-invasive
modality with the best diagnostic yield when seeking out
the origin of an obstacle, whatever the etiology, particularly
Table 3 TG severity criteria 2013/2018. with regard to malignant causes (sensitivity 96%, specificity
100%) and bile duct stenoses [12]. Lastly, EE and ERCP, which
Grade Criteria Threshold can be carried out if necessary during the same anesthetic
Grade 3: Cardiovascular Dopamine > 5 ␮g/kg/ procedure, have evinced similarly excellent performances in
Severe dysfunction min or any dose of detection of calculi; in addition, ERCP allows for therapeutic
At least 1 noradrenalin action [33]. That much said, a recent meta-analysis showed
criterium that MRI and EE performed as well as one another in detec-
Neurological Consciousness tion of common bile duct stones [34]. While the literature
dysfunction disorders often evokes the supposedly excellent diagnostic value of EE
Respiratory PaO2/FiO2 < 300 in cases of biliary neoplasia, there presently exists no study
dysfunction assessing with sufficient clarity its diagnostic performances.
Renal dysfunction Creatininuria > 176 In clinical practice:
␮mol/L or oliguria • hepatic ultrasound and abdominal MRI are non-invasive
Liver dysfunction INR > 1.5 and non-irradiating, but restricted availability of the lat-
Hematological Platelets < 100,000/ ter limits its utilization in emergencies, notwithstanding
dysfunction mm3 its excellent diagnostic performances;
Grade 2: Leucocytes < 4 G/L or > 12G/L • non-invasive but irradiant, abdominal and pelvic CT is of
Moderate interest due to its widespread availability, and diagnostic
At least 2 performances generally superior to ultrasound but inferior
criteria to MRI;
Fever > 39 ◦ C • while EE and ERCP are second-line invasive examinations,
Age > 75 years their diagnostic performances are excellent; ERCP is irra-
Bilirubinemia 85 ␮mol/L diant but allows for therapeutic action.
Hypoalbuminemia < 0.7 × ILN
Grade 1: Mild Microbiology
No criteria 2
or 3 The two key microbiological tests in case of acute cholan-
gitis are hemoculture and bile culture. Hemocultures were
PaO2: partial pressure of oxygen; FiO2: fraction of inspired positive in 40% of the episodes reported in a recent retro-
oxygen; INR: International normalized ratio; ILN: inferior limit spective multicenter series and even more positive in the
of the normal. event of biliary stent obstruction [11,35]. In 20% of cases,

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hemocultures may be polymicrobial [36]. Bile cultures are resistances, fluoroquinolones are not a recommended prob-
more often positive in 83% of cases according to the same abilistic antibiotic therapy. In any event, in order to reduce
multicenter study [11], but frequently more in other series) the risk of emergent multi-resistant organisms, antimicro-
and objectify polymicrobial infection in at least 50% of cases bial therapy must be secondarily adapted to bacteriological
[35,37,38]. A 2014 retrospective study showed total agree- test results.
ment of 31% between bile cultures and hemocultures, a In fact, the rationale for these associations revolves
finding raising the questions about the pathogenicity of the around a few fundamental issues. The first of these concerns
germs present in polymicrobial bile cultures, but over 70% of the need to take anaerobes into account in probabilis-
the tests were carried out more than 24 h after installation tic treatment, even though, due presumably to their low
of a biliary drain [37]. The main isolated germs are presented prevalence, the lnfectious Diseases Society of America
in Table 4, adapted from TG 2018 [39]: Escherichia coli and (IDSA) and the TG 2018 did so only in the case of biliary-
Klebsiella spp. are the two main germs responsible for acute enteric anastomosis [39,44]. The second issue involves the
cholangitis. debated pathogenicity of enterococci, which is supposed
As regards antibiotic resistance of the germs responsi- to be taken into account in empirical treatment only in
ble for acute cholangitis, more particularly the occurrence the event of severe infection, a nosocomial context or
of episodes implicating enterobacteria producing extended immunosuppression [44]. These recommendations should be
spectrum ␤-lactamases (ESBLs), data vary widely from one compared to the results of a recent retrospective study on
country to another; in Europe, a retrospective study on 573 episodes of acute bacterial cholangitis in two Japanese
the positive bile test results from 83 patients in a German tertiary centers, where it was found that lack of coverage
tertiary center identified 29% of multidrug-resistant (MDR) for enterococci and anaerobes was responsible for 30 and
bacteria, including 54% of ESBL [38]. In Korea, E. coli ESBLs 8% respectively of the 133 cases in which anti-microbial
are the first microorganisms responsible for acute cholan- therapy was inappropriate. However, more than 60% of
gitis, including community-acquired cholangitis, all in all acute cholangitis cases were care-associated or nosoco-
representing 30.4% of cases [40]. Biliary stenting is the one mial, and a substantial proportion of them were serious
MDR-independent risk factor identified in two retrospective episodes; 43% were grade III [36]. At an individual level,
studies, with relative risk of 3.6 to 4 times [38,41]. Presence the risk-benefit ratio of the addition of metronidazole, a
of a biliary endoprosthesis is also a risk factor for cholangi- molecule with few side effects when utilized for a short time
tis with enterococci (particularly E. faecium), Pseudomonas period, remains under discussion with regard to non-severe
aeruginosa and Stenotrophomonas maltophila [42]. Finally, community-acquired forms. Lastly, effective coverage of
even though colonization stents by fungal microorganisms Pseudomonas aeruginosa, of which the prevalence is highly
is a frequent occurrence, fungal cholangitis remains excep- variable, seems indispensable in patients fulfilling severity
tional [43]. criteria.
Biliary diffusion of antibiotics could represent a selection
Treatment of acute cholangitis criterion in anti-microbial therapy; and justify preference
of ceftriaxone to cefotaxime, notably in non-severe forms
Treatment of acute cholangitis is a response to an emergency due to its bilio-digestive excretion. However, studies con-
built around two fundamental procedures: antimicrobial ducted since 1976 on different antibiotics have shown that
therapy, and biliary tract drainage (Fig. 1). bile duct obstruction drastically reduced the biliary dif-
fusion of antibiotics. Even biliary excretion molecules are
well below minimal inhibitory concentrations (MIC) in bile
Antimicrobial therapy in cases involving bile duct obstruction [46—48]. These con-
The severity of acute cholangitis necessitates immediate siderations open debate on the usefulness of choosing an
antimicrobial therapy in emergency care, which is most antibiotic with satisfactory biliary diffusion and underline
often chosen probabilistically. Antibiotic treatment must the crucial importance of bile duct drainage.
cover the germs described above according to local ecology, Finally, the duration of antimicrobial therapy is also
without neglecting to take into consideration the relevant debated. The 2018 Tokyo Guidelines suggested 4 to 7 days
characteristics of the patient (renal and hepatic functions, after control of the source of infection, except with regard
allergies, known MRB colonization. . .) and of the antibi- to enterococci and streptococci, for which the recom-
otic, as well as the severity of the specific case of acute mended duration, due to a risk of endocarditis, is 2 weeks
cholangitis. [39]. However, the French Infectious Disease Society (SPILF)
Generally speaking, as regards community-acquired has proposed a reduction of anti-microbial therapy duration
forms without severity grade, the schema is based on to 3 days, including in cases of bacteremia (with the notable
3rd-generation cephalosporin (cefotaxime or ceftriaxone), exceptions of primary sclerosing cholangitis and liver trans-
associated with an anaerobic agent in cases involving biliary- plant recipients) [49]. The above recommendations are
enteric anastomosis. In initially severe, nosocomial or care- based on two studies. The first, conducted by Kogure et al.,
associated forms (including prostheses), preferred anti- was a single-center prospective study testing cessation of
microbial treatments include broad-spectrum cephalosporin anti-microbial therapy once body temperature has been
(cefepime) or an association piperacillin + tazobactam, both lower than 37 ◦ C for 24 h after bile duct drainage; as regards
of them associated with vancomycin and an anti-anaerobic the 18 patients included, among whom 17 presented with
in cases involving biliary-enteric anastomosis [39,44,45]. cholangiolithiasis, the median duration of anti-microbial
These schemas require adaptation to local ecology and to therapy was 3 days without relapse over the following 4
patients’ past history of infection and colonization (ESBL, weeks [50]. The second was a single-center retrospective
vancomycin-resistant enterococcus (VRE), etc.). A synthesis study of 80 patients comparing acute cholangitis relapse
of the different therapeutic schemas is proposed in Table 5. rates according to duration of anti-microbial therapy. The
Given high rates of resistance, even in cases of community- 41 patients having received anti-microbial therapy < 3 days
acquired infections and, more broadly, the development of did not relapse more often after median 71-day follow-up

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Table 5 Probabilistic anti-microbial therapy for acute cholangitis, as proposed in different recommendations.
Recommendations
Community-acquired Presence of Care-associated or
bilio-digestive nosocomial (including
Without severity With gravity anastomosis post-ERCP)
criterion criterion
SFAR (2004)[45] Amoxicillin/ Piperacillin/
clavulanic tazobactam
acid + gentamicin Imipenem
or netilmicin Ceftazidime +
Ticarcillin/ Metronidazole
clavulanic acid In association with
Piperacillin + Metronidazole amikacin
Cefoxitin
Cefotaxime or
Ceftriaxone +
Metronidazole
With serious
symptoms:
association of
gentamicin or
netilmicin
IDSA (2010, under Imipenem/ Imipenem/
revision) [44] Cilastatin Cilastatin
Meropenem Meropenem
Doripenem Doripenem
Piperacillin/ Piperacillin/
Tazobactam Tazobactam
Ciprofloxacin Ciprofloxacin
Levofloxacin Levofloxacin
Cefepime Cefepime
In association In association with
with metronidazole and
metronidazole vancomycin
TG 2018 [39] Severity TG grade Severity TG grade Severity TG grade Care-associated or
1 2 3 nosocomial (including
post-ERCP)
Cefazolina or Ceftriaxone or Piperacillin/ Piperacillin/
Cefotiama or Cefotaxime tazobactam tazobactam
Cefuroximea or Or Cefepime Cefepime or Cefepime or
Ceftriaxone or Or Cefozopran Ceftazidime or Ceftazidime or
Cefotaxime Or Ceftazidime Cefozopran Cefozopran
(+ metronidazole (+ Metronidazole (+metronidazole (+ metronidazole if
if bilio-digestive if bilio-digestive if bilio-digestive bilio-digestive
anastomosis) anastomosis) anastomosis) anastomosis)
Cefmetazolea Cefoperazone/ Imipenem/cilastatin Imipenem/
Cefoxitina sulbactam Meropenem cilastatin
Flomoxefa Ertapenem Doripenem Meropenem
Cefoperazone/ Ciprofloxacin or Ertapenem Doripenem
sulbactam levofloxacin or Aztreonam (+ Ertapenem
Ertapenem pazufloxacin or metronidazole if Aztreonam (+
Ciprofloxacin or moxifloxacin bilio-digestive metronidazole if
levofloxacin or (+ metronidazole anastomosis) bilio-digestive
pazufloxacin or if bilio-digestive In association anastomosis)
moxifloxacin anastomosis)b with vancomycin In association with
(+ Metronidazole vancomycin
if bilio-digestive
anastomosis)b
IDSA: infectious diseases Society of America; SFAR: Société française d’anesthésie et de réanimation; IDSA: TG2018: Tokyo Guidelines
2018, see Table 3 for severity criteria.
a According to local ecology (< 20% resistance).
b Only for patients allergic to beta-lactam antibiotics or following antibiogram.

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compared to those having received 4—5 days or > 5 days of or without sphincterotomy) during a second ERCP. Chole-
treatment [51]. cystectomy is subsequently carried out [9];
To sum up, probabilistic anti-microbial therapy must be • non-lithiasic cholangitis (especially when secondary to
initiated immediately after hemoculture testing and consists neoplasia) necessitates ERCP with insertion of an endo-
in a beta-lactam antibiotic covering entero-bacteria, while biliary prosthesis or a naso-biliary drain; while they are
anaerobic bacteria should probably be targeted only in cases similarly effective, the latter can cause patient discom-
involving biliary-enteric anastomosis, and enterococci only fort. It should also be noted that in two retrospective
in contexts of nosocomial context, high severity, or immun- studies involving 118 and 128 patients respectively, in
odepression. Duration of 5 days following drainage appears cases of hilar (Klatskin) tumor, endoscopic drainage by
sufficient. naso-biliary drain was found to be superior to drainage
by biliary prosthesis, insofar as it occasioned fewer
Bile duct obstruction treatment complications and/or reintervention [57,58];
• if ERCP drainage fails, two options may be: (1) per-
In cases of acute cholangitis, effective treatment of bile cutaneous drainage, possibly completed secondarily by
duct obstruction is of paramount importance. Post-surgical endoscopic stent placement using the ‘‘rendezvous’’ pro-
reflux cholangitis is an exception insofar as it generally does cedure, which permits removal of external drainage or (2)
not necessitate drainage due to the fact that for all prac- EE, but only in cases of non-lithiasic origin [59].
tical purposes, the bile has already been drained out [52].
In all other cases, drainage is an essential means of avoid- Choosing the optimal moment for biliary drainage is
ing septic shock, death and complications such as hepatic another, incompletely elucidated question of interest, even
abscesses; it also optimizes the action of antibiotics. Several if early drainage appears primordial [60]. A retrospective
modalities may be envisioned: surgical treatment (nowa- study on a large-scale sample (77,323 patients) high-
days exceptional due to its high morbi-mortality compared lighted longer hospital stays and higher costs in the event
to endoscopic treatment) [53], endoscopic drainage dur- of ERCP > 48 h [61]. Furthermore, two prospective studies
ing ERCP or EE through installation of a metallic or plastic involving 199 and 166 patients showed in multivariate anal-
prosthesis or a naso-biliary drain or, finally, percutaneous ysis that mortality risk was 3.6 times higher when ERCP was
transhepatic biliary drainage. carried out after 72 hours and that early biliary drainage per-
As regards the general principles of biliary (bile duct) formed within 24 h was a predictive factor of survival at 30
drainage, the current reference method is transpapillary bil- days (OR 0.23, CI95 [0.05—0.95]; P = 0.04) [62,63].
iary drainage during ERCP, either by placing a stent in the According to TG 2018, endoscopic treatment delay should
bile ducts, or by means of naso-biliary drainage; according be stratified according to cholangitis severity (cf. Table 3):
to a meta-analysis carried out in TG 2018, efficacy of the - for grade I, it is envisaged only in the event of failed anti-
two modalities is similar in terms of endoscopic and clinical microbial treatment; for grade 2, it is recommended early;
success, adverse effects, and risk of ‘‘redo’’ reinterven- for grade 3, it is recommended as a matter of urgency, with-
tion [9]. Association with ERCP endoscopic sphincterotomy out any precise indication of time lapse (in general in the
aimed at reducing occurrence of post-ERCP acute pancre- literature, emergency drainage takes place during the first
atitis should not be systematic insofar as its benefits remain 12—24 hours, and early drainage during the first 48 hours).
debatable; moreover, sphincterotomy is a complicated pro- However, this stratification necessitates validation, espe-
cedure with severe hemorrhaging in 4 to 8% of relevant cially insofar as an initial study did not find a correlation
cases [54,55]. according to degree of severity (except for grade 2) between
In the event of failure, percutaneous transhepatic or survival and time elapsed prior to drainage [28]. It also bears
echo-endoscopic drainage (EE) is generally proposed. A mentioning that in a retrospective study, it was suggested
recent meta-analysis (9 studies and 483 patients) showed that some patients classified in grade I were actually in need
better performances with EE (higher success rate and fewer of endoscopic drainage, a finding apparently in agreement
complications), but these positive results should be read- with the data detailed above [64].
justed due to probable bias in favor of EE [56].
In clinical practice: Treatment in particular cases
• in non-severe or moderate cholangiolithiasis, biliary In cases of liver abscess of biliary origin subsequently asso-
drainage is not systematically called for. In fact, stone ciated with bile duct obstruction, treatment consists in
removal is recommended subsequent to endoscopic anti-microbial therapy and biliary duct drainage associated
sphincterotomy, or else following balloon dilatation (in to a greater or lesser extent with abscess drainage. Anti-
the event of hemostatic disorders or small-scale lithiasis); microbial therapy need be adapted to identified germs;
when associated with extraction maneuvers, these proce- when relevant documentation is incomplete, anti-microbial
dure often suffices to effectively eliminate the obstacle. therapy similar to the treatment proposed above, and in
In the event of failure and persistent lithiasis in the com- Table 5, for acute cholangitis, may be recommended, tak-
mon bile duct, biliary drainage becomes necessary. The ing the two following particularities into close account: (1)
naso-biliary drain is more frequently used in Asia than since anaerobia represents 35 to 45% of the germs under
in Europe, where biliary endoprosthesis tends to be pre- consideration, systematic coverage can be justified; (2)
ferred on account of its relative simplicity; treatment duration is prolonged: 4 weeks when the abscess
• in cases of a large or multiple lithiases, and particularly in is small-scale or drained, and 6 weeks without drainage, if
the event of vesicular lithiasis, treatment is two-stepped. radio-clinic evolution is favorable. Biliary drainage is carried
First, biliary drainage is carried out according to the out as described above, and percutaneous drainage or punc-
modalities described above; second, lithiasis extraction ture aspiration of the abscess must be performed when size
is performed after dilatation with a larger balloon (with exceeds 5 cm [65].

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JVS-927; No. of Pages 11 ARTICLE IN PRESS
Acute cholangitis: Diagnosis and management 9

For patients with stenosis following digestive surgery, TG

2018 recommended ERCP assisted by balloon enteroscopy Key points
provided that experienced endoscopic surgeons are avail- • Acute cholangitis diagnosis is primarily clinical, and
able; its success rate is high. If it fails or is impossible, confirmed by biological and radiological data.
percutaneous trans-hepatic approach should be proposed. • While it has multiple etiologies, lithiasic and
In patients suffering from primary sclerosing cholangi- neoplastic obstacles are the two main causes.
tis, ERCP drainage is also indicated with balloon dilation of • The most frequently found germs are Escherichia coli
stenosis, and stenting need not necessarily be systematic. and Klebsiella spp.
What matters in these cases is to eliminate the cholangio- • Treatment associates antimicrobial therapy
carcinoma responsible for the stenosis; with this priority in targeting Enterobacteriaceae and adapted to
mind, the diagnostic performances of cholangioscopy are the environment (particularly in cases involving
superior to those of blind sampling [66]. biliary prosthesis or bilio-digestive anastomosis)
As concerns prevention of recurrent reflux cholangitis, to associated with endoscopic draining of the biliary
our knowledge up until now no study has validated medical ducts
treatment.
A simplified algorithm of cholangitis treatment is pro-
posed in Fig. 1.
Disclosure of interest
The authors declare that they have no competing interest.
Complications and prognosis
Notwithstanding improved treatment and management,
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Please cite this article in press as: Sokal A, et al. Acute cholangitis: Diagnosis and management. Journal of Visceral Surgery
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