Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)

Algorithm Steps

1. ▶

   Start

   Acute Cholangitis - Hepatobiliary Referral

   Complex/refractory cases or ERCP failure

   1. ●

      Action

      Hepatobiliary Assessment

      When is HPB consultation needed?

      • INDICATIONS FOR HPB CONSULT:
      • - Failed ERCP (2+ attempts)
      • - Complex biliary anatomy
      • - Surgical etiology (bile duct injury)
      • - Malignant biliary obstruction
      • - Grade III (severe) cholangitis
      • - Recurrent cholangitis
      1. ◆

         Decision

         TG18 Severity Grading

         Determines urgency

         • Grade I: Mild - No organ dysfunction
         • Grade II: Moderate - Risk factors
         • Grade III: Severe - Organ dysfunction
         1. ⚠

            Warning

            Grade III (Severe)

            URGENT biliary drainage

            • ANY ONE organ dysfunction:
            • - Hypotension requiring pressors
            • - Altered mental status
            • - PaO2/FiO2 <300
            • - Creatinine >2.0 mg/dL
            • - INR >1.5
            • - Platelets <100,000
            • REQUIRES:
            • - ICU admission
            • - Urgent drainage (<12-24h)
            • - Organ support
            1. ●

               Action

               Biliary Drainage Hierarchy

               HPB surgeon coordinates approach

               • 1. ERCP (if not failed/contraindicated)
               • - Success rate 90-95%
               • 2. PTC (percutaneous transhepatic)
               • - When ERCP fails
               • - Proximal obstruction
               • - Altered anatomy (Roux-en-Y)
               • 3. EUS-guided drainage (emerging)
               • 4. SURGICAL drainage (last resort)
               1. ●

                  Action

                  PTC Drainage

                  When ERCP not possible

                  • Percutaneous transhepatic cholangiography
                  • INDICATIONS:
                  • - Failed ERCP
                  • - Roux-en-Y anatomy
                  • - Proximal obstruction (Klatskin)
                  • - Duodenal obstruction
                  • TECHNIQUE:
                  • - US or fluoro-guided
                  • - Right > left approach usually
                  • - External drain initially
                  • - Can convert to internal later
                  1. ●

                     Action

                     Definitive Source Management

                     After stabilization

                     • CHOLEDOCHOLITHIASIS:
                     • - CBD clearance (ERCP/surgery)
                     • - Cholecystectomy (interval or same admission)
                     • MALIGNANT STRICTURE:
                     • - Staging workup
                     • - Metal stent vs surgery
                     • - Oncology consultation
                     • BILE DUCT INJURY:
                     • - Hepaticojejunostomy (delayed)
                     • - Referral to high-volume center
                     • BENIGN STRICTURE:
                     • - Serial dilation/stenting
                     • - Consider surgical bypass
                     1. ●

                        Action

                        Antibiotic Management

                        Empiric coverage

                        • EMPIRIC (before cultures):
                        • - Pip-Tazo 4.5g IV q6h OR
                        • - Ceftriaxone + Metronidazole OR
                        • - Meropenem (if MDR risk)
                        • ADJUST per culture results
                        • DURATION:
                        • - 4-7 days after source control
                        • - Longer if undrained/bacteremia
                        1. ●

                           Action

                           Post-Drainage Surveillance

                           Monitor for complications

                           • Serial LFTs (daily until improving)
                           • Repeat imaging if not improving
                           • Drain output monitoring
                           • Watch for: Recurrent cholangitis, abscess, leak
                           • Plan for definitive surgery if needed
                           1. ✓

                              Outcome

                              Outcomes

                              Prognosis

                              • Grade I: Mortality <1%
                              • Grade II: Mortality 5-10%
                              • Grade III: Mortality 10-30%
                              • Delay in drainage: Increased mortality
                              • Surgical drainage: Higher morbidity but effective
                  2. ⚠

                     Warning

                     Surgical Biliary Drainage

                     When interventional approaches fail

                     • INDICATIONS:
                     • - Failed ERCP + PTC
                     • - Peritonitis requiring laparotomy
                     • - Bile duct injury requiring repair
                     • - Gallbladder source (cholecystectomy)
                     • OPTIONS:
                     • - CBD exploration + T-tube
                     • - Cholecystostomy (if high-risk)
                     • - Choledochojejunostomy (rare acute)
                     • HIGH MORBIDITY in acute setting