7/10/2015

AcuteCholangitisFollowup:FurtherInpatientCare,Transfer,Deterrence/Prevention

AcuteCholangitisFollowup
Author:TimothyMScott,DOChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Nov10,2014

FurtherInpatientCare
AdmissiontoICUforillpatientsisappropriate.Continueintravenousantibioticsmonitorthebloodculturessothat
theantibioticscanbenarrowedtotheappropriatepathogen.Administerintravenousantibiotics1224hourspriorto
nonemergentERCP.ReferworseningpatientstoemergentERCPforsphincterotomyorpercutaneousdrainage.
Traditionally,antibioticswereadministeredfor710daystotreatcholangitis.However,itnowappearsthata3day
coursemaybesufficientinpatientswhoundergoadequatebiliarydrainage.
Inaddition,astudybyParketalindicatedthatinpatientswithacutecholangitiswithbacteremiawhohave
achievedsuccessfulbiliarydrainage,treatmentwithanearlyswitchfromintravenoustooralantibioticsisjustas
effectiveasconventional10dayintravenousantibiotictherapy.Thestudyinvolved59patients,including30who
underwentconventionalintravenousantibiotictreatmentand29whowereswitchedearlyintreatmenttooral
antibiotics.Atfollowup,30daysafterdiagnosis,theinvestigatorsdeterminedthatthebacterialeradicationratewas
notsignificantlydifferentbetweenthetwogroups,being93.3%fortheconventionaltreatmentpatientsand93.1%
fortheearlyswitchgroup.Moreover,thegroupsshowednostatisticallysignificantdifferencesintherecurrencerate
foracutecholangitisandthe30daymortalityrate. [12]

Transfer
Transferisappropriateinhospitalsunabletomanagesignificantlyillpatientswithintensivemedicalcare,surgery,
andendoscopicconsultation.
Optimizepatientstabilizationpriortotransfer.
Minimuminitialstabilizationincludesthefollowing:
Appropriatediagnostics
ABCs(includingvolumeresuscitation)
Administrationofbroadspectrumantibiotics
Criticalcaretransport

Deterrence/Prevention
ProphylacticantibioticspriortoERCPmaydecreaseriskofcholangitis.
Promptrecognitionandtreatmentofsymptomaticcholelithiasisinpatientsathigherriskforcomplications(eg,those
withdiabetes)decreaseriskofcholangitis.
AggressivesearchforCBDstonesduringdiagnosisandtreatmentofcholecystitismaybenecessarytoprevent
cholangitis.

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.

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AcuteCholangitisFollowup:FurtherInpatientCare,Transfer,Deterrence/Prevention

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.

References
1. AronJH,BowlusCL.Theimmunobiologyofprimarysclerosingcholangitis.SeminImmunopathol.2009
Sep.31(3):38397.[Medline].[FullText].
2. KashyapR,MantryP,SharmaR,etal.Comparativeanalysisofoutcomesinlivinganddeceaseddonor
livertransplantsforprimarysclerosingcholangitis.JGastrointestSurg.2009Aug.13(8):14806.[Medline].
3. vanErpecumKJ.Gallstonedisease.Complicationsofbileductstones:Acutecholangitisandpancreatitis.
BestPractResClinGastroenterol.2006.20(6):113952.[Medline].
4. RosingDK,DeVirgilioC,NguyenAT,ElMasryM,KajiAH,StabileBE.Cholangitis:analysisofadmission
prognosticindicatorsandoutcomes.AmSurg.2007Oct.73(10):94954.[Medline].
5. KinneyTP.Managementofascendingcholangitis.GastrointestEndoscClinNAm.2007Apr.17(2):289
306,vi.[Medline].
6. JabaraB,FargenKM,BeechS,SlakeyDR.Diagnosisofcholangiocarcinoma:acaseseriesandliterature
review.JLaStateMedSoc.2009MarApr.161(2):8994.[Medline].
7. AttasaranyaS,FogelEL,LehmanGA.Choledocholithiasis,ascendingcholangitis,andgallstone
pancreatitis.MedClinNorthAm.2008Jul.92(4):92560,x.[Medline].
8. RustemovicN,CukovicCavkaS,OpacicM,etal.Endoscopicultrasoundelastographyasamethodfor
screeningthepatientswithsuspectedprimarysclerosingcholangitis.EurJGastroenterolHepatol.2010
Jun.22(6):74853.[Medline].
9. IorgulescuA,SanduI,TurcuF,IordacheN.PostERCPacutepancreatitisanditsriskfactors.JMedLife.
2013Mar15.6(1):10913.[Medline].[FullText].
10. SharmaBC,AgarwalN,SharmaP,SarinSK.Endoscopicbiliarydrainageby7Fror10Frstent
placementinpatientswithacutecholangitis.DigDisSci.2009Jun.54(6):13559.[Medline].
11. ItoiT,KawaiT,SofuniA,etal.Efficacyandsafetyof1steptransnasalendoscopicnasobiliarydrainage
forthetreatmentofacutecholangitisinpatientswithpreviousendoscopicsphincterotomy(withvideos).
GastrointestEndosc.2008Jul.68(1):8490.[Medline].
12. ParkTY,ChoiJS,SongTJ,etal.Earlyoralantibioticswitchcomparedwithconventionalintravenous
antibiotictherapyforacutecholangitiswithbacteremia.DigDisSci.2014Nov.59(11):27906.[Medline].
MedscapeReference2011WebMD,LLC

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