Diagnosis and Management of Acute Cholangitis

Observations

Diagnosis of AC traditionally relied on the presence of the Charcot triad, which has since proven to incompletely capture the complexity of this condition. Modern-day diagnosis, severity grading, and management guidelines provide a more holistic approach. Tokyo Guidelines (TG) are widely used, though newer guidelines, namely the BILE criteria, have recently emerged. These criteria include demonstration of inflammation, cholestasis, and biliary obstruction. Ultrasound is first-line imaging modality with computed tomography or magnetic resonance cholangiopancreatography often used for diagnostic dilemmas. Treatment is dependent on severity, though guidelines generally recommend early decompression (most commonly with endoscopic retrograde cholangiopancreatography [ERCP]) for moderate to severe cases. The optimal timing of biliary drainage remains unclear, with mixed evidence from observational studies and no universal definition of what constitutes “early” vs “urgent” drainage. Laparoscopic cholecystectomy should be performed during index hospitalization, when possible, with multiple studies demonstrating lower morbidity and mortality rates when compared with interval procedures. The prognosis of AC is favorable if treated swiftly and appropriately; in turn, mortality rates increase with severity and delays in diagnosis.