Skip to content
BY-NC-ND 3.0 license Open Access Published by De Gruyter Open Access July 8, 2014

Management of acute cholecystitis and acute cholangitis in emergency setting

  • Kui-Hin Liau EMAIL logo , Catherine Teh and Alejandro Serrablo
From the journal Open Medicine


Acute biliary infection (acute cholecystitis and acute cholangitis) is one of the common emergency conditions which carries significant morbidity and mortality. The risk factors are often associated with gallstones, biliary stasis and bile infection. Gram-negative bacteria are frequent isolates from bile and blood cultures in infectious cholangitis. Endotoxaemia from the gram-negative microbes results in circulatory shock and organ dysfunction. Therefore, prompt diagnosis with severity stratification and recognition of its potential rapid progression to life-threatening shock and multi-organ failure ensure execution of the three fundamental interventions in the initial management strategy, namely: resuscitation to support the organ, antimicrobial therapy and biliary decompression drainage to control the infection. This is the core principle in the management of severe acute cholangitis.

[1] Gouma DJ, Obertop H. Acute calculous cholecystitis. What is new in diagnosis and therapy? HPB Search in Google Scholar

[2] Sharp KW. Acute Cholecystitis. Surg Clin North Am. 1988;68:269–279 10.1016/S0039-6109(16)44477-4Search in Google Scholar

[3] Williamson RC. Acalculous disease of the gallbladder. Gut. 1988;29:860–872 in Google Scholar

[4] Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg 1995;180:232–244 Search in Google Scholar

[5] Merriam LT, Kanaan SA, Dawes LG, Angelos P, Prystowsky JB, Rege RV, et al. Gangrenous cholecystitis: analysis of risk factors and experience with laparoscopic cholecystectomy. Surgery 1999;126:680–685 in Google Scholar

[6] Bedirli A, Sakrak O, Sozuer EM, Kerek M, Guler I. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology. 2001;48:1275–1278 Search in Google Scholar

[7] Kimura Y, Takada T, Kawarada Y, Nimura Y, Hirata K, Sekimoto M, et al. Definitions, pathophysiology and epidemiology of acute cholangitis and cholecystitis: Tokyo guidelines. 2007;14:15–26 10.1007/s00534-006-1152-ySearch in Google Scholar

[8] Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, et al. Prognostic factors for the development of gangrenous cholecystitis. Am J Surg. 2003;186(5):481–485 in Google Scholar

[9] Charcot M. De la fievre hepatique symptomatique. Comparaison avec la fievre uroseptique. Lecons sur les maladies du foie des voies biliares et des reins. Paris: Bourneville et Sevestre; 1877:176–185 Search in Google Scholar

[10] Reynolds BM, Dargan EL. Acute obstructive cholangitis. A distinct syndrome. Ann Surg 1959;150:299–303 in Google Scholar

[11] Longmire WP. Suppurative cholangitis. In: Hardy JD, editor. Critical surgical illness. New York: Saunders; 1971;p397–424 Search in Google Scholar

[12] Andrew DJ, Johnson SE. Acute suppurative cholangitis, a medical and surgical emergency. A review of 10 years. Am J Gastroenterol 1970;54:141–154. Search in Google Scholar

[13] Boey JH, Way LW. Acute Cholangitis. Ann Surg. 1980;191(3):264–270 in Google Scholar

[14] Fan ST, Lai ECS, Mok FPT, Choi TK, Wong J. Acute cholangitis secondary to hepatolithiasis. Arch Surg. 1991;126(8):1027–1031 in Google Scholar

[15] Lipsett PA, Pitt HA. Acute cholangitis. Surg Clin North Am. 1990;70:1297–1312 10.1016/S0039-6109(16)45285-0Search in Google Scholar

[16] Welch JP, Donaldson GA. The urgency of diagnosis and surgical treatment of acute suppurative cholangitis. Am J Surg. 1976;131:527–532 in Google Scholar

[17] O’Connor MJ, Schwartz ML, McQuarrie DG, Sumer HW. Acute bacterial cholangitis: an analysis of clinical manifestation. Arch Surg 1982;117:427–441 10.1001/archsurg.1982.01380280031007Search in Google Scholar PubMed

[18] Kiriyama S, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Pitt HA, et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2013;20:24–34 in Google Scholar PubMed

[19] Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, et al. TG13 diagnotic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2013;20:35–46 in Google Scholar PubMed

[20] Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, Sekimoto M, et al. Tokyo guidelines for management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg. 2007;14:1–126 in Google Scholar PubMed PubMed Central

[21] Sugiyama M, Atomi Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch Surg. 1997;132:1129–1133 in Google Scholar PubMed

[22] Ralls PW, Hall J, Lapin SA, Quinn MF, Morris UL, Boswell W. Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis. J Clin Ultrasound. 1982;10:113–115 in Google Scholar PubMed

[23] Stiris MG, Tennoe B, Aadland E, Lunde OC. MR Cholangiopancreaticography and endoscopic retrograde cholangiopancreaticography in patients with suspected common bile duct stones: a prospective blinded study. Acta Radiologica. 2000;41(3):269–272 in Google Scholar PubMed

[24] Kondo S, Isayama H, Akahane M, Toda N, Sasahira N, Nakai Y, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography and helical-computed-tomographic cholangiography. Eur J Radiol. 2005;54(2):271–275 in Google Scholar PubMed

[25] NIH Consensus State Sci Statement. NIH state-ofthe- science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. 2002 Jan 14–16;19(1):1–26 Search in Google Scholar

[26] Marne C, Pallares R, Martin R, Sitges-Serra a. Gangrenous cholecystitis and acute cholangitis associated with anaerobic bacteria in bile. Eur J Clin Microbiol. 1986;5:35–39 in Google Scholar PubMed

[27] Claesson B, Holmlund D, Matzsch T. Microflora of the gallbladder related to duration of acute cholecystitis. Surg gynecol Obstet 1986;162:531–535 Search in Google Scholar

[28] Yoshida M, Takada T, Kawarada Y, Tanaka A, Nimura Y, Gomi H, et al. Antimicrobial therapy for acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg. 2007;14:83–90 in Google Scholar PubMed PubMed Central

[29] Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133–164 (CPG) in Google Scholar PubMed

[30] Gomi H, Solomkin JS, Takada T, Strasberg SM, Pitt HA, Yoshida M, et al. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:60–70 in Google Scholar PubMed

[31] Saharia PC, Cameron JL. Clinical management of acute cholangitis. Surg Gynecol Obstet. 1976 Mar;142(3):369–372 Search in Google Scholar

[32] Chang W, Lee K, Wang S, Chuang S, Kuo K, Chen J, et al. Bacteriology and antimicrobial susceptibility in biliary tract disease: an audit of 10-years’ experience. Kaohsiung J Med Sci. 2002;18:221–228 Search in Google Scholar

[33] Maluenda F, Csendes A, Burdiles P, Diaz J. Bacteriological study of choledochal bile in patients with common bile duct stones, with or without, acute suppurative cholangitis. Hepatogastroenterology. 1989;36:132–135 Search in Google Scholar

[34] Csendes A, Mitru N, Maluenda F, Diaz J, Burdiles P, Csendes P, et al. Counts of bacteria and pyocites of choledochal bile in controls and patients with gallstoens or common bile duct stones with or without acute cholangitis. Hepatogastroenterology 1996;43:800–806 Search in Google Scholar

[35] Solomkin J, Mazuski J, Baron E, Sawyer R, Nathens A, DiPiro J, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 2003;37:997–1005 in Google Scholar PubMed

[36] Tanaka A, Takada T, Kawarada Y, Nimura Y, Yoshida M, Miura F, et al. Antimicrobial Therapy for Acute Cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14:59–67 in Google Scholar PubMed PubMed Central

[37] Nielsen M, justesen T. Anaerobic and aerobic bacteriological studies in biliary tract disease. Scand J Gastroenterol. 1976;11:437–446 10.1080/00365521.1976.12097131Search in Google Scholar

[38] Lesprit P, Brun-Buisson C. Hospital antibiotic stewardship. Curr Opin Infect Dis. 2008;21(4):344–349 in Google Scholar PubMed

[39] Owens RC Jr. Antimicrobial stewardship: concepts and strategies in the 21st century. Diagn Microbial Infect Dis. 2008 May;61(1):110–128 in Google Scholar PubMed

[40] Yeung YP, Yip AWC. Predictors for emergency biliary decompression in acute cholangitis. European Journal of Gastroenterology & Hepatology. 2006;18(7):727–731 in Google Scholar PubMed

[41] Thompson JE, Tompkins RK, Longmire WP. Factors in management of acute cholangitis. Ann Surg. 1982;195(2):137–145 in Google Scholar PubMed PubMed Central

[42] Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL. Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg 1986;73:988–992 in Google Scholar PubMed

[43] Gogel HK, Runyon BA, Volpicelli NA, Palmer RC. Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy. Gastrointest Endose 1987;33:210–213 in Google Scholar

[44] Lau JY, chung SC, Leung JW, Ling TK, Yung MY, Li AK. Endoscopic drainage aborts endotoxaemia in acute cholangitis. Br J Surg. 1996;83:181–184 in Google Scholar

[45] Leung J, Chan R, Cheung S, Sung J, Chung S, French G. The effect of obstruction on biliary excretion of cefoperazone and ceftazidime. J Antimicrob Chemother. 1990;25:399–406 in Google Scholar

[46] Van den Hazel S, de vries X, Speelman P, Dankert J, Tytgat G, huuibregtse K, et al. Biliary excretion of ciprofloxacin and piperacillin in the obstructed biliary tract. Antimicrob Agents Chemother. 1996;40:2658–2660 10.1128/AAC.40.11.2658Search in Google Scholar

[47] Sharma BC, Kumar r, Agarwal N, Sarin SK. Endoscopic biliary drainage by nasobiliary drain or by stent placement in patients with acute cholangitis. Endoscopy. 2005;37:439–443 in Google Scholar

[48] Chen MF, Jan YY, Lee TY. Percutaneous transhepatic biliary drainage for acute cholangitis. Int Surg. 1987;72:131–133 Search in Google Scholar

[49] Leung JW, Chung SC, Sung JJ, Banez VP, Li AK. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1989;10:1307–1309 in Google Scholar

[50] Hui CK, Liu CL, Lai KC, Chan SC, Hu WHC, Wong WM, et al. Outcome of emergency ERCP for acute cholangitis in patients 90 years of age and older. Alimentary Pharmacology & Therapeutics. 2004 Jun;19(11):1153–1158 in Google Scholar

[51] Lai ECS, Mok FPT, Tan ESY, Lo CM, Fan ST, You KT, et al. Endoscopy Biliary Drainage for Severe Acute Cholangitis. N Engl J Med; 1992 June;326:1582–1586 in Google Scholar

[52] Lai EC, Paterson IA, Tam PC, Choi TK, Fan ST, Wong J. Severe acute cholangitis: the role of emergency nasobiliary drainage. Surgery. 1990 Mar;107(3):268–272 Search in Google Scholar

[53] Sharma BC, Agarwal DK, Baijal SS, Sraswat VA, Choudhuri G, Naik SR. Endoscopic management of acute calculous cholangitis. J Gastroenterology and Hepatology. 1997 Dec;12(12):874–876 in Google Scholar

[54] Lee DW, Chan AC, Lam YH, Ng EK, Lau JY, Law BK, et al. Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial. Gastrointest Endosc 2002;56:361–365 in Google Scholar

[55] Tsuyuguchi T, Takada T, Kawarada Y, Nimura Y, Wada K, Nagino M, et al. Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14:35–45 in Google Scholar

[56] Nagino M, Takada T, Kawarada Y, Nimura Y, Yamashita Y, Tsuyuguchi T, et al. Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14:68–77 in Google Scholar

[57] Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–918 in Google Scholar

[58] Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T,et al. Single balloon enteroscopy-assisted ERCP in 206 patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am J Gastroenterol. 2010;105:93–99 in Google Scholar

[59] Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64:52–59 in Google Scholar

[60] Saleem A, Baron TH, Gostout C, Topazian MD, Levy MJ, Petersen PT, et al. Endoscopic retrograde cholangiopancreatography using singleballoon enteroscope in patients with altered Rouxen-Y anatomy. Endoscopy. 2010;42:656–660 in Google Scholar

[61] Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangio-drainage of the bile: report of 4 cases. Gastrointest Endosc. 2003;57:246–251 in Google Scholar

[62] Itoi T, Tsuyuguchi T, Takada T, Strasberg SM, Pitt HA, Kim MH, et al. TG13 indications and techniques for biliary drainage in acute cholangitis (with videos) J Hepatobiliary Pancreat Sci. 2013;20:71–80 in Google Scholar

[63] Szabo S, Mendelson MH, Mitty HA, Bruckner HW, Hirschman SZ. Infections associated with transhepatic biliary drainage devices. Am J Med. 1987;82:921–926 in Google Scholar

[64] Audisio RA, Morosi C, Bozzetti F, Cozzi G, Bellomi M, Pisani P, et al. The outcome of cholangitis after percutaneous biliary drainage in neoplastic jaundicve. HPB Surg. 1993;6:287–293 in Google Scholar PubMed PubMed Central

[65] Burke DR, Lewis CA, cardella JF, Citron SJ, Drooz AT, Haskal ZJ, et al. Society of Interventional Radiology Standards of Practice Committee Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage. J Vasc Interv Radiol. 2003;14:243–246 Search in Google Scholar

[66] Pessa ME, Hawkins IF, Vogel SB. The treatment of acute cholangitis: percutaneous transhepatic biliary drainage before definitive therapy. Ann Surg 1987;205:389–392 in Google Scholar

[67] Saltzstein EC, Peacock JB, Mercer LC. Early operation for acute biliary tract stone disease. Surgery 1983;94:704–708 Search in Google Scholar

[68] Khashab MA, Tariq A, Tariq U Kim K, Ponor L, Lennon AM, et al. Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clin Gastroenterol Hepatol 2012;10:1157–1161 in Google Scholar

[69] Gigot JF, Leese T, Dereme T, Coutinho J, Castaing D, Bismuth H. Acute cholangitis. Multivariate analysis of risk factors. Ann Surg. 1989 Apr;209(4):435–438 in Google Scholar

[70] Inui K, Nakazawa S, naito Y, Kimoto E, Yamao K. Nonsurgical treatment of cholecystolithiasis with percutaneous transhepatic cholecystoscopy. Am J Gastroenterol 1988;83:1124–1127 Search in Google Scholar

[71] Boland GW, Lee MJ, Mueller PR, Dawson SL, Gaa J, Lu DS, et al. Gallstones in critically ill patients with acute calculous cholecystitis treated by percutaneous cholecystotomy: nonsurgical therapeutic options. Am J Roentfgenol AR. 1994;162:1101–1103 in Google Scholar

[72] Tsuyuguchi T, Itoi T, Takada T, Strasberg SM, Pitt HA, Kim MH, et al. TG13 indications and techniques for gallbladder drainage in acute cholecystitis (with videos) J. Hepatobiliary Pancreat Sci. 2013;20:81–88 in Google Scholar

[73] Shirai Y, Tsukada K, Kawaguchi H, Ohtani T, Muto T, Hatakeyama K. Percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis. Br J Surg. 1993;80:1440–1442 in Google Scholar

[74] Tsuyuguchi T, Takada T, Kawarada Y, Nimura Y, Wada K, Nagino M, et al. Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14:46–51 in Google Scholar

[75] Chopra S, Dodd GD, Mumbower AL, Chintapalli KN, Schwesinger WH, Sirinek KR. et al. Treatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystotomy. Am J Roentgenol AJR 2001;176:1025–1031 in Google Scholar

[76] Itoi T, Itokawa F, Kurihara T. Enoscopic ultrasonography-guided gallbladder drainage: actual technical presentations and review of the literature (with videos) J Hepatobiliary Pancreat Sci. 2011;18:282–286 in Google Scholar

[77] Flowers JL, Bailey RW, Scovill WA, Zucker KA. The Baltimore experience with laporoscopic manangement of acute cholecystitis. Am J Surg 1991;161:388–392 in Google Scholar

[78] Zacks SL, Sandler RS, Rutledge R, Brown RS. A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterology 2002;97:334–340 in Google Scholar

[79] Araujo-Teixeria JP, Rocha-Reis J, Costa-Cabral A, Barros H, Saraiva AC, Araujo-Teixeira AM. Laparoscopic versus open cholecystectomy for cholecysytitis (200 cases) Comparison of results and predictive factors for conversion. Chirurgie 1999;124:529–535 in Google Scholar

[80] Banz V, Gsponer T, Candinas D, Güller U. Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy. Ann. Surg. 2011;254(6):964–970 in Google Scholar

[81] Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, et al. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:89–96 in Google Scholar

[82] Giger UF, Michel JM, Opitz I, Inderbitzin DT, Kcher T, Krähenbühl L, et al. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery Database. J Am Coll Surg. 2006 nov;203(5):723–728 in Google Scholar

[83] Rhodes M, Sussman L, Cohen L, Lewis. Randomized trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet, 1998;351(9097):159–161 in Google Scholar

[84] Berthou JC, Drouard F, Charbonneau P, Moussalier K. Evaluation of laparoscopic manangment of common bile ducts in 220 patients. Surg Endosc. 1998;12(1):16–22 in Google Scholar PubMed

[85] Clayton ESJ, Connor S. Alexakis N. Leandros E. Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg.2006;93(10):1185–1191 in Google Scholar PubMed

[86] Gigot J F, Leese T, Dereme T, Coutinho J, Castaing D, Bismuth H. Acute cholangitis. Multivariate analysis of risk factors. Ann Surg. 1989;209(4):435–438 in Google Scholar PubMed PubMed Central

[87] Salek J. Livote E, Sideridis K, Bank S. Analysis of risk factors predictive of early mortality and urgent ERCP in acute cholangitis. J Clin Gastroenterol. 2009 Feb;43(2):171–175 in Google Scholar PubMed

[88] Lai ECS, Tam PC, Paterson IA, Ng MT, Fan ST, Choi TK, Wong J. Emergency surgery for severe acute cholangitis. The high-risk patients. Ann Surg. 1990;211(1) 55–59 in Google Scholar PubMed PubMed Central

Published Online: 2014-7-8
Published in Print: 2014-6-1

© 2014 Versita Warsaw

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Downloaded on 2.3.2024 from
Scroll to top button