Table 10 Clinical pathway for patients with acute cholangitis is illustrated

Clinical signs and symptoms

Diagnosis

 • Intermittent fever with rigors

 • Jaundice

 • Right upper quadrant abdominal pain

Laboratory markers

 • Increased white blood cell count

 • C-reactive protein

 • Total bilirubin and direct bilirubin

 • Alkaline phosphatase

 • Gamma-glutamyl transpeptidase

 • Aspartate aminotransferase and Alanine aminotransferase

Imaging

 • US

 • CT

 • MRI

 • Endoscopic ultrasound (EUS)

 • ERCP

 • Endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic drainage can be carried out either by external drainage using a nasobiliary tube or internal drainage using biliary stenting. Both the modalities of internal and external drainage have their own advantages and disadvantages. Both have similar technical and clinical success rates.

Treatment

 • Percutaneous transhepatic biliary drainage (PTBD) should be reserved for patients in whom ERCP fails. PTBD can lead to significant complications, including biliary peritonitis, haemobilia, pneumothorax, hematoma, liver abscesses, and patient discomfort related to the catheter.

 • Open drainage may be indicated for patients who cannot undergo such noninvasive drainage procedures, for anatomical and structural reasons, including patients after Roux-en-Y choledochojejunostomy with a propensity for hemorrhage.

Amoxicillin/clavulanate 2.2 g every 6/8 h +/− gentamicin 5–7 mg/Kg every 24 h

Antibiotic therapy

Avoid Amoxicillin/clavulanate if local Enterobacteriaceae resistances > 20%.

Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g every 6 h or 16 g/2 g by

continuous infusion +/− gentamicin 5-7 mg/Kg every 24 h (in critically ill patients)

Ceftriaxone 2 g every 24 h + metronidazole 500 mg every 8 h

Cefotaxime 2 g every 8 h + metronidazole 500 mg every 8 h

or

In patients with beta-lactam allergy

A fluoroquinolone-based regimen

Ciprofloxacin 400 mg every 8/12 h + metronidazole 500 mg every 8 h

or

In patients at high risk for infection with community-acquired ESBL-producing Enterobacteriaceae

One of the following antibiotics

Tigecycline 100 mg LD, then 50 mg every 12 h (carbapenem-sparing strategy)

Ertapenem 1 g every 24 h

Meropenem 1 g every 8 h (only in patients with septic shock)

Doripenem 500 mg every 8 h (only in patients with septic shock)

Imipenem/cilastatin 500 mg every 6 h (only in patients with septic shock)

In patients at high risk for infection from enterococci including immunocompromised patients or patients with recent antibiotic exposure, consider the use of ampicillin 2 g every 6 h if patients are not being treated with Piperacillin/tazobactam or imipenem/cilastatin (active against ampicillin-susceptible enterococci) or tigecycline.