7/10/2015

AcuteCholangitisTreatment&Management:PrehospitalCare,EmergencyDepartmentCare,Consultations

AcuteCholangitisTreatment&Management
Author:TimothyMScott,DOChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Nov10,2014

PrehospitalCare
Diagnosisofcholangitisisnotaprehospitaldiagnosis.Mildcholangitismaypresentwithabdominalpain,jaundice,
andfever.Whentransportingthesepatientstothehospital,placethepatientonamonitorandinsertanintravenous
(IV)line.
Inunstablepatientswithcholangitis,prehospitalcareshouldincludethefollowing:
ImmediateassessmentofABCs
Monitoring(eg,pulseoximetry,cardiacmonitor,frequentbloodpressuremeasurements,bloodglucose
measurement)
Stabilization(eg,oxygen,placementof2largeboreIVs,administrationofIVfluidstounstablepatients)
Rapidtransport

EmergencyDepartmentCare
Suspectmildcholangitisinpatientswithjaundiceandafeverconsidercholangitisinallpatientswithsepsis.
Thedegreeofurgencyoftreatmentdependsonseverityofillness.Importantpointsareresuscitation,diagnosis,
andtreatment.
Managementofacutecholangitisintheemergencydepartmentincludesthefollowing:
AfterassessmentoftheABCs,placethepatientonamonitorwithpulseoximetry,provideoxygenvianasal
canula,andobtainanECG.Drawandsendlaboratorystudies(includingbloodcultures)whenthe
intravenouslineisplaced.
ProvidefluidresuscitationwithIVcrystalloidsolution(eg,0.9%normalsaline).
Administerparenteralantibioticsempiricallyafterbloodculturesaredrawn.Donotdelayadministrationof
antibioticsifbloodculturescannotbedrawn.
Correctanyelectrolyteabnormalitiesorcoagulopathies.
Formanagementofpatientsinsepticshock,seeShock,Septic.
Standardtherapyforcholangitisconsistsofbroadspectrumantibioticswithcloseobservationtodetermine
theneedforemergencydecompressionofthebiliarytree.
Anasogastrictubemaybehelpfulforpatientswhoarevomiting.
Patientsshouldbenothingbymouth(NPO).PlaceaFoleycatheterinillpatientstomonitorurineoutput.
Thesurgicalliteraturestatesthat,inpatientswithmildcholangitis,8090%respondtomedicaltherapy. [3]
Approximately15%donotrespondandsubsequentlyrequireimmediatesurgicalorendoscopicdecompression.
Mortalityratesapproach100%forpatientswhofailmedicaltherapyanddonothavesurgicaldecompression.
Inseverelyillpatients,treatmentisimmediatebiliarydecompression.Themethoddependsonthedegreeofillness.
Inthepast,drainagewasperformedsurgically.Today,optionsofpercutaneousorendoscopicdrainageexistin
additiontomedicalmanagementwithantibiotics.Endoscopicdrainagehasbeenshowntodecreasemortalityrates
from30%to10%.
Medicaltherapycanbecomplementarytosurgicalorendoscopictreatments.Inlessillpatients,medicaltreatment
maybeallthatisnecessary.Performthefollowing:
Maintainmedicaltherapyandconsiderelectivesurgerywithpatientswhoshowimprovement.Patientswho
arebeingmedicallymanagedanddonotimproveorwhodeteriorateshouldrapidlybereferredtoundergo
eitherERCP,sphincterotomy,orpercutaneousdrainage.Seethemanagementalgorithmbelow.

Algorithmformanagementofpatientswithacutecholangitis.

Themainstayoftherapyisdrainage.ERCPisthebestmethodtoaccomplishbiliarydrainage.Astudyby
Sharmashowedequalsafetyandeffectivenesswhenusinga7Frstentor10Frstentforbiliarydrainagein
patientswithseverecholangitis. [10]
AnoveltechniquethatisbeingusedinAsiainthesurgicalmanagementofacutecholangitisisendoscopic
nasobiliarydrainage. [11]

Consultations
Immediatelyconsultasurgeonandagastroenterologist.
Althoughmostpatientsrespondtoantibioticsandconservativecare,asubsetrequiresemergentprocedures(eg,

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AcuteCholangitisTreatment&Management:PrehospitalCare,EmergencyDepartmentCare,Consultations

ERCP,percutaneousdrainage).Indecidingtodrain,consultwithagastroenterologistandasurgeon.
Increasedmortalityisobservedinpatientswithhypotension,acuterenalfailure,liverabscess,cirrhosis,high
malignantstrictures,femalegender,andadvancedage.Therefore,considerdecompressionearlierforthese
patients.Patientswithmalignantobstructionusuallydonotrespondtoantibiotics(59%comparedto85%).
Unstablesepticpatientsrequireclinicaljudgmenttodetermineiftheywillsurviveuntilmedicaltherapyhasachance
toworkoriftheyrequireemergencydecompressionwithitsassociatedhighmortalityrate.

ContributorInformationandDisclosures
Author
TimothyMScott,DOChiefResident,DepartmentofEmergencyMedicine,DetroitMedicalCenter,Wayne
StateUniversitySchoolofMedicine
TimothyMScott,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,AmericanOsteopathicAssociation,EmergencyMedicine
Residents&#039Association
Disclosure:Nothingtodisclose.
Coauthor(s)
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
JeffreyAManko,MDAssistantProfessorofEmergencyMedicine,Director,EmergencyMedicineResidency
Program,ConsultingStaff,EmergencyMedicineServices,NewYorkUniversity/BellevueMedicalCenter
JeffreyAManko,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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