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Submitted 10 Aug. 2023
Accepted 06 Nov. 2023
Citation
H Mustamin, Z Azwan, K
Nizar.Biliary Drainage For
Sepsis Control In Acute
Cholangitis: A Case Report
:BJOSS::2025:(4);119-125
Biliary Drainage For Sepsis Control In Acute
Cholangitis: A Case Report
H Mustamin
1*
, Z Azwan
1
, and K Nizar
2
1
Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM), Kuala
Lumpur, Malaysia
2
Department of Anaesthesiology, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM),
Kuala Lumpur, Malaysia
*
Correspondence author : Hadija Mustamin, Email: deejdija5992@gmail.com
O R IGI N A L
Abstract
Acute cholangitis leading to sepsis is a common occurrence, especially in populations with a high
prevalence of gallstones. Unfortunately, the mortality rate related to this issue is high. Recently,
we had a case involving an elderly woman who initially had mild acute cholangitis, but it progressed
into a severe case. Respiratory and hematological issues developed, along with worsening septic
parameters and liver functions. As a result, she was intubated, ventilated, and monitored in the
intensive care unit (ICU). Urgent ERCP failed, but PTBD and percutaneous cholecystostomy were
inserted to aid in biliary decompression and sepsis control. Currently, she is recovering from
sepsis and plans for early ERCP and cholangiogram before definitive surgical intervention. To
handle obstructed biliary sepsis, early biliary drainage is crucial for urgent biliary decompression
and sepsis control, alongside fluid resuscitation, intravenous antibiotics, and intensive care.
Keywords : Percutaneous cholecystostomy, endoscopic nasobiliary drainage (ENBD), percu-
taneous transhepatic biliary drainage (PTBD), biliary decompression, endoscopic retrograde
cholangiopancreatography (ERCP).
Introduction
Sepsis is a highly concerning medical condition that can lead to organ dysfunction due to the
body’s response to infection (
1
). This condition has a high mortality rate, affecting between
one in three and one in six individuals (
1
). Acute cholangitis is a common biliary sepsis type
that arises due to obstruction of the biliary system caused by a tumor or stone, leading to the
accumulation of microorganisms as a result of increased pressure (
2
;
3
). Patients with severe
cholangitis and organ complications require careful monitoring in the Intensive Care Unit (ICU) and
effective resuscitation (
1
). Early biliary decompression is critical in controlling sepsis, and there
are numerous methods available, including ERCP with stent insertion, PTBD, ENBD percutaneous
cholecystostomy, and open drainage (
4
). To provide a case illustration, we present a patient who
suffered from severe cholangitis and underwent three biliary drainages, including ERCP, PTBD,
and percutaneous cholecystostomy, for effective sepsis control.
Case Report
A 61-year-old woman named Madam H, who has underlying comorbidity diabetes mellitus type 2,
hypertension, dyslipidemia, and cholelithiasis, went to HUKM’s emergency department with right
hypochondriac pain that lasted for a day. She did not experience any fever, tea-colored urine,
or pale stool. During the examination, her blood pressure was normotensive at 141/77 mmHg,
but her heart rate was tachycardic at 103 bpm. She had a respiratory rate of 18 breaths/min, a
temperature of 36.8°C, and an SPO2 of 99% under room air. Her abdomen revealed tenderness
at the right hypochondriac region, yet there was no Murphy’s sign, and no evidence of peritonism
was found.
After conducting blood tests, it showed that her total bilirubin was elevated at 103, and her liver
function test (LFT) was deranged with ALT 201, ALP 312, and AST 203. Other blood parameters
were within the normal range. Urgent ultrasonography of the hepatobiliary system was done,
which showed a thickened gallbladder wall with lithiasis and a dilated common bile duct (CBD)
of 0.8 cm. However, no intraductal lesion or calculus was seen. Diagnosis of mild cholangitis
was made. Madam H was admitted to the general ward and given intravenous antibiotics (IV
Augmentin 1.2 g TDS).
After two hours of being admitted to the general ward, the patient experienced a temperature
spike of 38.5°C and shortness of breath with a respiratory rate of 33 breaths per minute. She
required oxygen supplementation through a venturi mask set to 60% to maintain an SPO2 level
above 95%. Upon examination of her lungs, bilateral crepitation was detected. An arterial blood
gas test revealed type 1 respiratory failure with a pH of 7.43, a PCO2 level of 32, a PO2 level
of 73, an HCO3 level of 22.5, and a BE of -3.2. A repeated FBC showed an elevated TWBC
of 15.2 and thrombocytopenia with a platelet count of 80. Her LFT was increasing in trends,
and the coagulation profile noted a prolonged INR of 1.53. Chest radiography revealed bilateral
haziness. As a result, non-invasive ventilation (NIV)-BIPAP was used for oxygen support, and she
was diagnosed with severe (Grade III) ascending cholangitis due to respiratory and hematological
involvement. Her IV antibiotic was escalated from IV Augmentin to IV Tazocin and fresh frozen
plasma (FFP) transfusion was given to correct coagulopathy. Blood culture and sensitivity showed
a gram-negative rod.
The patient’s condition continued to worsen, and she became more tachypneic despite being on
NIV. She was intubated and ventilated to prevent respiratory collapse and resuscitated. An urgent
endoscopic retrograde cholangiopancreatography (ERCP) was performed, but CBD cannulation
was unsuccessful due to the edematous ampulla of Vater. As a result, the ERCP was abandoned.
Following the procedure, she remained persistently hypotensive despite fluid resuscitation. Hence,
an intravenous infusion of noradrenaline was started to maintain a mean atrial pressure (MAP)
above 65 mmHg. She was then transferred to the intensive care unit (ICU) for close monitoring
and. Her condition progressed from mild to severe ascending cholangitis. Since the ERCP failed,
percutaneous transhepatic biliary drainage (PTBD) was inserted.
Figure 1. The ultrasonography of the hepatobiliary system reveals a dilated CBD measuring 0.81
cm. This typically indicates an obstructed biliary system, which is often caused by a CBD stone
or tumor. However, the study did not find any intraductal lesion or calculus. As a result, urgent
ERCP is necessary for both diagnostic and therapeutic purposes
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Figure 2. Cholangiogram was performed while inserting a PTBD, which revealed a dilated CBD
with abrupt termination at distal CBD/ampulla junction. No filling defect at CBD is seen.
Peripheral and main intrahepatic ducts are not dilated. Multiple gallbladder calculi are noted
and he tip of the PTBD is located within duodenum
After examining the cholangiogram images of PTBD, a percutaneous cholecystostomy was per-
formed in consultation with the general surgeon. The procedure successfully drained purulent bile.
The blood culture and sensitivity test showed the growth of Klebsiella Sp. Based on the blood
culture’s sensitivity; the antibiotic was changed to IV Unasyn 3 g TDS. The patient’s respiratory
function improved gradually, and she required low ventilation settings. Her septic parameters
and LFT also improved, and she no longer needed inotropic support. The patient will undergo
early ERCP and cholangiogram prior to definitive surgery.
Discussion
According to the Sepsis Surviving campaign in 2021, sepsis is a life-threatening dysfunction of
the organs caused by an unregulated response to infection. Septic shock, on the other hand,
is defined as sepsis with persistent hypotension requiring inotropic support despite adequate
fluid resuscitation. Septic shock is also defined by the need for a vasopressor to maintain a
patient’s mean arterial pressure (MAP)
≥
65 mmHg and serum lactate level
≥
2 mmol/L (
1
;
5
).
Since the first consensus definition of sepsis (Sepsis-1) in 1991, the number of cases of sepsis
and septic shock has steadily increased, reaching about 49 million cases of sepsis and 11 million
sepsis-related deaths worldwide in 2017 (
6
). Sepsis kills between one in three and one in six of
those it affects (1).
Acute cholangitis is a bacterial infection of the hepatobiliary system. It occurs when biliary stenosis
whether partial or complete obstruction present in the bile duct or hepatic ducts. The obstruction
can be caused by various benign causes (such as bile duct stones, stricture, or occlusion of
a stent) or the presence of a tumor, resulting in cholestasis and biliary infection. This biliary
stenosis or blockage elevates pressure in the biliary system and flushed the microorganisms or
endotoxins from the infected bile into the systemic circulation, inducing a systemic inflammatory
response (
3
). In other postulation, acute bacterial cholangitis or widely known as ascending
cholangitis comes from the migration of bacteria from the duodenum into the common bile duct.
But, rarely, translocation of bacteria from the portal vein into the bile duct can also occur (2; 3).
It is important to know how to diagnose and grade acute cholangitis to properly stratify the
patient, and whether the case can be managed in the general ward or need urgent intervention
and monitoring in the critical intensive care unit (ICU). Previously, acute cholangitis has been
diagnosed based on Charcot’s triad. Studies have shown that Charcot’s triad has high specificity
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in diagnosing acute cholangitis but has a low sensitivity of around 26% (
3
). The lack of evidence
in this field has prompted specialists to establish a consensus. The first guideline was established
in 2007 and the recent revised guideline was in 2018 namely Tokyo Guideline 2018 (TG18) for
diagnostic criteria and severity grading of acute cholangitis (3).
The diagnostic criteria for acute cholangitis are based on clinical signs and symptoms, routine
blood tests, and diagnostic imaging. While the severity grading is divided into Grade I (Mild), II
(Moderate), and III (Severe) acute cholangitis. The severity grading criteria for acute cholangitis
are important for predicting prognosis and determining a treatment strategy, especially identifying
patients that require early biliary drainage (
3
). Table 1 in the APPENDIX section shows the
TG18/TG13 diagnostic criteria for acute cholangitis while Table 2 shows the severity grading of
acute cholangitis (3).
Sepsis caused by acute cholangitis, particularly in moderate and severe acute cholangitis must be
treated promptly to prevent septic shock and multiorgan dysfunctions as a patient can deteriorate
rapidly. Even with modern treatment, the mortality of sepsis secondary to acute cholangitis can
be up to 27% (
3
). Initial fluids resuscitation and antibiotic must be administrated as per recommen-
dation by Sepsis Surviving Campaign 2021 (
1
). For sepsis control, urgent biliary decompression
must be arranged immediately once the patient is stable after adequate resuscitation (7).
In terms of biliary decompression and drainage, it can be divided into open or endoscopic drainage
and internal and external drainage. The most commonly practiced endoscopic drainage is en-
doscopic retrograde cholangiopancreatography (ERCP). Via ERCP, a stent can be inserted for
internal drainage to decompress the biliary system. A Cholangiogram and removal of stone will
be performed later on once the patient is out of sepsis and more stable (4).
Those patients who cannot undergo endoscopic drainage will be subjected to external drainage.
The widely known procedures for external drainage are endoscopic nasobiliary drainage (ENBD)
and percutaneous transhepatic biliary drainage (PTBD). ENBD has advantages where no additional
sphincterotomy is required, clogging in the tube (external drain) can be washed out and bile cultures
can be done. However, because of the patient’s discomfort from the transnasal tube placement,
self-extraction and dislocation of the tube are likely to occur, especially in elderly patients. Loss
of electrolytes and fluid as well as collapse of tubes by twisting, may also occur (
4
). For PTBD, it is
inserted under ultrasound guided by an interventional radiologist and as per principle. However,
PTBD may cause serious complications including intraperitoneal hemorrhage, biliary peritonitis,
and a long hospital stay. ERCP and PTBD are also considered difficult procedures as it needs
experienced hands to perform the procedure. In ERCP and PTBD, the failure rates are up to 11%
and 19% respectively (4).
Percutaneous cholecystostomy is another method for external biliary drainage. It is commonly
performed in treating acute cholecystitis. Very few studies explain the role of percutaneous
cholecystostomy in the management of acute cholangitis (
7
). It is applied in treating acute
cholangitis, particularly for patients who are critical and unstable for neither endoscopic or PTBD
and those who had failed endoscopic drainage. The procedure itself is straightforward. The
operator will aim at the distended gallbladder that easily be seen on ultrasound. It is amenable to
puncture even if the patient is less cooperative. Therefore, it can be performed in a single attempt
of puncture and the procedure can be completed in less than 10 minutes if it is performed by an
experienced operator/radiologist (7).
Percutaneous cholecystostomy can also be performed at the bedside in the ward or ICU with a
portable ultrasound machine. It can help to reduce the risk of transferring unstable patients to
the endoscopy or interventional radiology suite. In addition, the success rate for percutaneous
cholecystostomy is almost 100% (
7
). However, despite the risk and benefits of each external and
internal drainage method, previous RCTs have shown there is no difference between external
drainage and stent placement (internal drainage) for treating acute cholangitis (
4
). The choice
of drainage is based on the patient’s general condition and the availability of endoscopic/PTBD
facilities and expertise in each hospital.
For the open technique, T-Tube insertion is commonly performed. It is indicated for patients who
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cannot undergo such noninvasive procedures due to anatomical and structural reasons, such as
patients who had undergone Roux-en-Y choledochojejunostomy procedures. In open drainage,
the goal is similar which is to decompress the biliary system. Simple procedures such as T-tube
placement without choledocholithotomy should be recommended. This is because long hours of
operations should be avoided in such ill patients (3).
Conclusion
Sepsis is a life-threatening organ dysfunction due to infection which has high mortality and
morbidity. While acute cholangitis is the most common cause of biliary sepsis which can progress
rapidly into septic shock and fatal. Diagnosing and grading acute cholangitis is important to
stratified patients and helps in the next treatment plans. Early biliary drainage for decompression
is needed for sepsis control in obstructed biliary sepsis. Biliary decompression can be achieved
by ERCP and stenting, ENBD, PTBD, or open drainage. Percutaneous cholecystostomy is also
another method of biliary drainage in acute cholangitis. The choice of drainage must be chosen
properly based on the patient’s general condition and the availability of the facility in each hospital.
Conflict Of Interest
All authors declare no conflict of interest of any kind.
References
[1]
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving
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[2]
Ahmed M. Acute cholangitis-an update. World journal of gastrointestinal pathophysiology.
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[3]
Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, et al. Tokyo Guidelines
2018: diagnostic criteria and severity grading of acute cholangitis (with videos). Journal of
Hepato-Biliary-Pancreatic Sciences. 2018;25(1):17-30.
[4]
Tsuyuguchi T, Takada T, Kawarada Y, Nimura Y, Wada K, Nagino M, et al. Techniques of biliary
drainage for acute cholangitis: Tokyo Guidelines. Journal of hepato-biliary-pancreatic surgery.
2007;14:35-45.
[5]
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The
third international consensus definitions for sepsis and septic shock (Sepsis-3). Jama.
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[6]
Guarino M, Perna B, Cesaro AE, Maritati M, Spampinato MD, Contini C, et al. 2023 Update
on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department.
Journal of Clinical Medicine. 2023;12(9):3188.
[7]
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Appendix
Diagnostic Criteria and Severity Grading of Acute Cholangitis according to Tokyo Guideline 2018.
Table 1. TG18/TG13 diagnostic criteria for acute cholangitis
A. Systemic inflammation
A-1. Fever and/or shaking chills
A-2. Laboratory data: evidence of inflammatory response
B. Cholestasis
B-1. Jaundice
B-2. Laboratory data: abnormal liver function tests
C. Imaging
C-1. Biliary dilatation
C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)
Suspected diagnosis: one item in A + one item in either B or C
Definite diagnosis: one item in A, one item in B and one item in C
Note:
A-2: Abnormal white blood cell counts, increase of serum C-reactive protein
levels, and other changes indicating inflammation
B-2: Increased serum ALP, r-GTP (GGT), AST, and ALT levels Other factors
which are helpful in diagnosis of acute cholangitis include abdominal pain
(right upper quadrant or upper abdominal) and a history of biliary disease
such as gallstones, previous biliary procedures, and placement of a biliary
stent. In acute hepatitis, marked systematic inflammatory response is ob-
served infrequently. Virological and serological tests are required when
differential diagnosis is difficult.
Thresholds:
A-1 Fever B-T >38°C
A-2
Evidence
of inflam-
matory
response
WBC count
(× 1.000/µL)
CRP(mg/dL)
<4 or >10 ≥1
B-1 Jaundice
T-Bil
≥
2 (mg/dL)
B-2
Abnormal
liver func-
tion tests
ALP (IU)
GTP (IU)
AST (IU)
ALT (IU)
>1.5× STD
>1.5× STD
>1.5× STD
>1.5× STD
Cited from Kiriyama et al.[4]
ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate
aminotransferase, CRP C-reactive protein, r-GTP (GGT) r glutamyltrans-
ferase, WBC white blood cell
STD: upper limit of normal value
124/125
Table 2. TG18/TGI3 severity assessment criteria for acute cholangitis [4]
Grade III (severe) acute cholangitis
"Grade III" acute cholangitis is defined as acute cholangitis that is associated with the onset of
dysfunction at least in any one of the following organs/systems:
1. Cardiovascular dysfunction: hypotension requiring dopamine
≥
5 µg/kg per min, or any
dose of norepinephrine
2. Neurological dysfunction: disturbance of consciousness
3. Respiratory dysfunction: PaO2 /FiO2, ratio <300
4. Renal dysfunction: oliguria, serum creatinine >2.0 mg/dl
5. Hepatie dysfunction: PT-INR >1.5
6. Hematological dystunction: platelet count <100,000/mm³
Grade II (moderate) acute cholangitis
"Grade II" acute cholangitis is associated with any two of the following conditions:
1. Abnormal WBC count (>12,000/mm³, <4,000/mm³)
2. High fever (≥39°C)
3. Age (≥75 years old)
4. Hyperbilirubinemia (total bilirubin ≥5 mg/dl)
5. Hypoalbuminemia (<STD"x0.7)
Grade I (mild) acute cholangitis
""Grade I" acute cholangitis does not meet the criteria of "Grade III (severe)" or ""Grade II
(moderate)" acute cholangitis at initial diagnosis.
Early diagnosis, early biliary drainage and/or treatment for etiology, and antimicrobial adminis-
tration are fundamental treatment for acute cholangitis classified not only "Grade III (severe)"
and "Grade II (moderate)" but also "Grade I (mild)".
Therefore, it is recommended that patients with acute cholangitis who do not respond to the
initial medical treatment (general supportive care and antimicrobial therapy) undergo early
biliary drainage or treatment for etiology (see flowchart). Cited from Kiriyama et al. [4] STD:
lower limit of normal value
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