14

Emergent Treatment of Acute Cholangitis and

Acute Cholecystitis
Rakesh Navuluri, MD1 Matthew Hoyer, BS2 Murat Osman, BS3 Jonathan Fergus, MD1

1 Department of Radiology, The University of Chicago, Chicago, Illinois
2 The Johns Hopkins University School of Medicine, Baltimore,
Maryland
3 George Washington University School of Medicine, Washington,
District of Columbia
Address for correspondence Rakesh Navuluri, MD, Department of
Radiology, The University of Chicago, 5841 S. Maryland Avenue,
MC 2026, Chicago, IL 60637 (e-mail: rnavuluri@gmail.com).

Semin Intervent Radiol 2020;37:14–23

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Abstract Acute pathology of the biliary tract including cholangitis and cholecystitis can lead to
Keywords biliary sepsis if early decompression is not performed. This article provides an overview
► cholangitis of the presenting signs and symptoms and role of interventional radiology in the
► cholecystitis management of patients with acute cholangitis or acute cholecystitis. It is especially
► interventional important to understand the role of IR in the context of other treatment options
radiology including medical management, endoscopy, and surgery.
► biliary drainage

Interventional radiology plays an integral role in the man-
agement of patients with acute biliary conditions, including
acute cholecystitis and acute cholangitis. Percutaneous
drainage of an obstructed biliary system can prevent biliary
sepsis in patients who may not be candidates for traditional
first-line therapies including medical therapy and endosco-
py. Here, we review the pathophysiology, diagnosis, percu-
taneous treatment, complications, outcomes, and alternate
treatment options of acute cholecystitis and cholangitis.
Acute Cholecystitis
Definition
Cholecystitis is inflammation of the gallbladder, most often
in the setting of outflow obstruction due to the presence of
gallstones, which is referred to as calculous cholecystitis.
Less commonly, the gallbladder may become inflamed in the
absence of gallstones, referred to as acalculous cholecystitis.
Symptoms
The classic presentation of acute cholecystitis involves right
upper quadrant abdominal pain, fever, nausea, and vomiting.
There may also be pain in the epigastrium or radiating to the
right shoulder or back. The pain is often severe and pro-
longed in nature, and frequently follows fatty food ingestion.
Abdominal examination typically reveals voluntary and
involuntary guarding, with a positive Murphy’s sign. Using
cholescintigraphy as the gold standard, a positive Murphy’s
sign has been shown to have a sensitivity of 97% and a
specificity of 48%.1 Laboratory findings may include leuko-
cytosis but do not commonly include elevated total serum
bilirubin or alkaline phosphatase, which may be signs of
cholangitis or choledocholithiasis.
Etiology
Calculous cholecystitis comprises approximately 90% of
cholecystitis cases and is thought to arise from gallstones
causing outflow obstruction of the gallbladder, resulting in
gallbladder distention and wall edema, ultimately culminat-
ing in ischemia and necrosis (referred to as gangrenous
cholecystitis) if left untreated.2 While the initial inflamma-
tion is typically sterile, it is often followed by bacterial
superinfection. One study of patients with gallstone disease
found that 46% of patients with acute cholecystitis had
positive gallbladder cultures, most commonly with bacteria
such as Escherichia coli, Klebsiella, and Enterococcus.3 In cases
of superinfection by gas-forming bacteria, gas may accumu-
late within the gallbladder wall or lumen, resulting in
emphysematous cholecystitis. If left untreated, acute calcu-
lous cholecystitis may progress to perforation, abscess

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 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
formation, or generalized peritonitis. Gallbladder perfora-
tion has been shown to occur in up to 10% of acute cholecys-
titis cases, with mortality ranging between 12 and 16%.4
Although acalculous cholecystitis is clinically indistin-
guishable from calculous cholecystitis, its etiology is quite
different and often multifactorial. The pathogenesis of acalcu-
lous cholecystitis is thought to arise due to biliary stasis or
ischemia in the setting of serious illness, such as trauma, burn
injury, surgery, shock, sepsis, or total parenteral nutrition.
Gallbladder stasis leads to concentration of bile salts and
gallbladder distention, eventually resulting in tissue necrosis.
Secondary infections are common and include similar enteric
pathogens to those implicated in calculous cholecystitis,
including E. coli, Klebsiella, and Enterococcus.5 Complications
may occur in as many as 40% of cases and include perforation,
gangrene, and empyema, with mortality ranging from 10 to
90% depending on the timing of the diagnosis.6
Diagnosis
Initial laboratory investigation should rule out other causes of
abdominal pain as well as complications of acute cholecystitis
and should thus include a complete blood count, serum lipase
and amylase, and a complete metabolic panel including liver
transaminases, albumin, bilirubin, and calcium.
While acute cholecystitis should be suspected in all
patients with right upper quadrant or epigastric pain, fever,
and leukocytosis, the diagnostic criterion of the updated
2018 Tokyo Guidelines requires the presence of imaging
findings characteristic of acute cholecystitis in addition to
signs of local and systemic inflammation.7 Abdominal ultra-
sound is the preferred initial imaging modality to assess for
both calculous and acalculous cholecystitis, especially in the
acute setting. Key sonographic features of acute cholecystitis
include gallbladder wall thickening (>4–5 mm for calculous
cholecystitis and 3.5–4 mm for acalculous cholecystitis), a
sonographic Murphy’s sign (inspiratory arrest during deep
breathing while the gallbladder is being sonographed), and
subserosal edema. Other findings may include intramural
gas, echogenic bile or sludge, and hydrops.
A systematic review of 30 studies demonstrated that ultra-
sonography had a sensitivity of 88% and a specificity of 80% for
the diagnosis of acute cholecystitis. In the case of calculous
cholecystitis, ultrasonography was also shown to be useful in
the identification of gallstones, with a sensitivity and specificity
of 84 and 99%, respectively.8 However, ultrasonography is less
likely to identify stones or fragments under 3 mm.9 Gallbladder
wall thickening is the most reliable sonographic feature of
acalculous cholecystitis but is not specific, as this may also be
the result of hypoalbuminemia, ascites, or sludge.10
As cholescintigraphy takes several hours to perform, it is
not recommended in the acute setting. However, when the
diagnosis remains uncertain, cholescintigraphy can help
demonstrate patency of the cystic and common bile ducts.
Morphine augments the entry of the radioactive tracer into
the gallbladder by increasing the sphincter of Oddi pressure,
thereby increasing the pressure gradient for the movement
of the tracer. Failure to visualize the gallbladder 30 minutes
following morphine augmentation or on delayed imaging is
Navuluri et al. 15
likely caused by cystic duct obstruction due to edema and is
diagnostic of acute cholecystitis.
Contrast-enhanced computed tomography (CT) scans and
magnetic resonance cholangiopancreatography (MRCP) may
be indicated to rule out alternative causes of abdominal pain
or to evaluate for complications of cholecystitis. CT findings
may include gallbladder wall edema, pericholecystic strand-
ing, and high-attenuation bile.11 Some gallstones may be
isodense with bile, thereby decreasing the sensitivity of CT
for detecting gallstones. Overall, abdominal CT is sensitive
(94%) but not very specific (59%) for the diagnosis of acute
cholecystitis.12 Nevertheless, CT is often utilized to rule out
serious complications such as perforation, emphysematous
cholecystitis, or gallstone ileus in patients with signs of
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sepsis, peritonitis, crepitus, or bowel obstruction. MRCP is
useful in evaluating for concurrent choledocholithiasis but is
less sensitive than ultrasound in detecting gallbladder wall
thickening. For this reason, it is often reserved for patients
with acute cholecystitis and elevated liver transaminases or
total bilirubin, or those with common bile duct dilation on
ultrasound.
Management
The Tokyo Guidelines, most recently updated in 2018, define
cases of acute cholecystitis by severity.7 Grade I cases are mild
in severity and are managed by early laparoscopic cholecystec-
tomy in patients at low surgical risk, defined as the Charlson
comorbidity index (CCI)
5 and American Society of Anesthesi-
ologists physical status classification (ASA-PS)
2. In those at
higher surgical risk, antibiotics and supportive care can be
provided prior to surgery. Grade II and III cases involve severe
local inflammation or organ dysfunction and require antibiotics
and supportive care prior to more definitive treatment. In
optimal surgical candidates (CCI
5 and ASA-PS
2 for grade
II cases, CCI
3 and ASA-PS
2 for grade III cases), early
cholecystectomy remains the mainstay of therapy in these
patients. However, many patients carry comorbid medical
conditions and are at high risk for morbidity and mortality
with surgical intervention. In these cases, placement of a
cholecystostomy tube decompresses and drains the inflamed
gallbladder, and typically serves as a bridge to delayed laparo-
scopic cholecystectomy. In poor surgical candidates, successful
cholecystostomy tube placement may also serve as definitive
therapy.13,14
Preprocedure
Coagulopathy and ascites are relative contraindications to
percutaneous cholecystostomy. In accordance with SIR Guide-
lines for procedures with high risk of bleeding, coagulopathy
should be corrected such that INR
1.5 to 1.8 and platelets
should be transfused for counts < 50,000/μL. Low-dose aspirin
does not need to be withheld prior to the procedure.
Preprocedural antibiotics should be administered within
1 hour of the start of the procedure. Recommendations for
antibiotics should cover common biliary organisms, including
extended-spectrum β-lactamase producing E. coli. Options
include a carbapenem, a fluoroquinolone, or ampicillin-
sulbactam.15
Seminars in Interventional Radiology Vol. 37 No. 1/2020
16 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis Navuluri et al.

As always, detailed history and physical examination

should be obtained, and recent imaging studies should be
reviewed. Common anatomic considerations include ascites,
interposed bowel loops, and low diaphragmatic recess. In the
case of significant ascites, paracentesis may be performed
prior to continuing with the cholecystostomy.

Procedure
There are three important variables to consider when planning
a cholecystostomy tube placement: imaging modality, route,
and technique. Ultrasound guidance is quicker and less costly,
and may also be performed at bedside. This can be particularly
beneficial in intensive care unit (ICU) patients who are too ill to
transport to interventional radiology. Doppler imaging also

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allows for real-time assessment of overlying abdominal wall
vessels. However, we prefer to perform all ultrasound proce-
dures in an angiography suite to allow for real time visualiza-
tion of catheter and wire placement and also to perform
cholangiography. CT guidance may be preferable if there is
concern for overlying bowel or artifact from intraluminal gas. Fig. 1 Percutaneous transhepatic cholecystostomy access using a 21-
Percutaneous cholecystostomy drains may be placed via gauge needle (arrow) (Seldinger technique) with ultrasound guidance.
either a direct transperitoneal or a transhepatic approach
route. Transhepatic placement allows for more catheter sup-
port and stable positioning within the liver parenchyma. This
is particularly important when treating an emphysematous
gallbladder with a friable wall. Transhepatic placement also
reduces the risk of bile leakage into the peritoneum should the
drain become dislodged and may also permit faster maturation
of catheter tract. On the other hand, puncture of the liver
capsule and parenchyma potentially increases the risk of
bleeding. Having noted these differences, a recent retrospec-
tive observational study by Beland et al noted no difference in
outcome between these two routes.16
In terms of procedural technique, drains may be placed
either by Seldinger or trochar technique. The latter is preferred
by some due to the theoretical risk of bile leakage and conse-
quent bile peritonitis during the exchange of wires and cathe-
ters involved when using the Seldinger technique. Additionally,
trochar technique can be quicker as fewer steps are involved.
Ultimately, the procedural technique and route chosen
depend on the operator’s comfort level and preference. At
our institution, the generally preferred method is transhe- Fig. 2 Retraction of cholecystostomy tube 4 weeks after initial
patic/Seldinger (►Fig. 1). We leave an 8.5-Fr drain to bulb placement via transperitoneal route, with extravasation of contrast
suction after the gallbladder has been manually decom- into the peritoneum (white arrows). Note also the tortuous course of
the catheter (black arrow) as a result of gallbladder decompression.
pressed. However, we occasionally use the trochar technique
This ultimately resulted in loss of access and necessitated placement
in a dilated gallbladder via a transperitoneal route for ease and of a new cholecystostomy tube.
simplicity. We recommend using a smaller catheter (6 or 7 Fr)
in these cases, as larger catheters can be more difficult to
trochar into the gallbladder lumen. It is worth mentioning that because the gallbladder will
eventually decompress, subsequent drain retraction can
Postprocedure occur (►Fig. 2). This can lead to leakage of bile and peritonitis
Drains are routinely exchanged every 4 to 6 weeks until defini- if not recognized early. Subsequent exchange of transper-
tive treatment with surgery. In the case of acalculous cholecys- itoneal drains can also become more challenging for this
titis, drains may be removed once there is clinical resolution of same reason, unlike with transhepatic drains.
inflammation, and fluoroscopic confirmation of cystic duct
patency and maturation of the catheter tract. In our experience, Complications
tract maturation requires at least 4 to 6 weeks, though periods of The overall complication rate for percutaneous cholecystos-
2 to 3 weeks have been reported in the literature. tomy has been reported between 2 and 16%.17,18 Major

Seminars in Interventional Radiology Vol. 37 No. 1/2020

 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
complications include sepsis, significant bleeding, and bile
leak with resulting peritonitis. Sepsis may occur after
instrumentation of an infected biliary system, but signs of
systemic infection are usually present prior to the procedure.
Despite this, sepsis attributable to percutaneous cholecys-
tostomy has been reported to be 0.9%.17 Bile peritonitis is a
rare but serious complication that may occur due to over-
distention of the gallbladder with contrast or due to tube
retraction with the presence of a side hole outside the
gallbladder lumen, resulting in intraperitoneal bile leak.
Other rare complications described in the literature include
pneumothorax, bowel injury, and abscess formation.19
Minor complications include tube dislodgement and bile
leak. Tube dislodgement is the most common minor complica-
tion of percutaneous cholecystostomy, with reported frequen-
cies between 4 and 15%.20 Dislodgement can be due to a
collapsed gallbladder or can be caused by the simple movement
of the liver and gallbladder during normal respiration. Tube
retention can be promoted using locking catheters and by
coiling as much tubing as possible within the gallbladder at
the time of placement. Bile leak may be due to ascites, which can
be managed by paracentesis or placement of a side hole outside
the gallbladder lumen. Further management can be attempted
via catheter upsizing or placement of a colostomy bag around
the tube. In the setting of leakage due to catheter occlusion,
routine tube exchange is advised.
Outcomes
Technical success in percutaneous cholecystostomy place-
ment is 95% or higher.18 Failures are most frequently due to
issues with access, often in the setting of wall calcification,
stone impaction, or a decompressed gallbladder.
Clinical success varies greatly based on disease severity
and overall treatment plan. In a study of 5,329 patients with
grade III acute cholecystitis in Japan and Taiwan, the lowest
mortality (0.79%) was achieved in patients who underwent
initial percutaneous cholecystostomy followed by cholecys-
tectomy, while the highest mortality (13.5%) was seen in
those who underwent cholecystostomy without subsequent
cholecystectomy. These results most likely reflect the poor
health status of the latter group, which likely precludes them
from receiving definitive surgical treatment. Nonetheless,
these findings have been supported by other studies in the
literature.21,22 A recent randomized, multicenter clinical
trial in the Netherlands compared treatment with laparo-
scopic cholecystectomy to percutaneous cholecystostomy in
high-risk patients with acute calculous cholecystitis.23 This
trial demonstrated similar overall mortality between the
two treatment groups. However, the major complication
rate, including recurrent biliary disease and reintervention,
was lower in those who received cholecystectomy (12 vs.
65%). Furthermore, healthcare costs were reduced by more
than 30% in the surgical group. These studies suggest that
while laparoscopic cholecystectomy is the preferred treat-
ment option in the sickest patients, percutaneous cholecys-
tostomy may benefit select patients who would benefit from
cholecystectomy by providing them with additional time for
their condition to improve prior to surgery. Of note, the
Navuluri et al. 17
incidence of biliary injury during cholecystectomy may be
slightly higher following percutaneous cholecystostomy
(1.6%) compared with surgeries without preceding chole-
cystostomy (0.08–1.1%), a complication associated with sig-
nificant morbidity and mortality.24
Alternative Procedures
While the standard definitive treatment of acute cholecystitis
remains to be cholecystectomy, patients who are poor surgical
candidates due to either high-risk comorbidities or poor
performance status require other noninvasive options as
either a temporary measure for interval cholecystectomy or
for permanent, long-term treatment. Several alternative, min-
imally invasive procedures have been elucidated in the litera-
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ture, including endoscopic transpapillary gallbladder drainage
(ETGBD) with cystic duct stenting (ETGBS) and endoscopic
ultrasound-guided gallbladder drainage (EUSGBD). These
alternative procedures have been proposed as an option for
certain high-risk patients with acute cholecystitis including
those with coagulopathy, large-volume abdominal ascites, or
other comorbidities that may preclude percutaneous drain
placement.
Endoscopic gallbladder drainage has recently been pro-
posed as a method to drain the gallbladder in high-risk
patients with acute cholecystitis after failing conventional
measures such as percutaneous transhepatic gallbladder
drainage/aspiration (PTGBA/D) or in patients with end-stage
liver disease due to advanced cancer or those awaiting liver
transplantation. This method is generally performed through
endoscopic retrograde cholangiopancreatography (ERCP) in
either a transpapillary or transmural approach, whereby
selective bile duct cannulation is achieved and a wire is
negotiated into the cystic duct or gallbladder through which
a double-pigtail stent or nasocholecystic drain is deployed
crossing the ampulla with the proximal and distal pigtails in
the gallbladder and duodenum, respectively. Reported adverse
events include pancreatitis, biliary perforation, and rarely
stent migration and cholangitis. Technical success can be
affected by not only technical skill but also aberrant biliary
anatomy or degree of inflammation.25 Thus, a high degree of
technical expertise is needed to successfully perform this
procedure.
Endoscopic ultrasound-guided gallbladder drainage (EUS-
GBD) is a technique whereby the gallbladder is punctured from
the body or antrum of the stomach or duodenal bulb under
direct EUS visualization. This is achieved by inserting a guide-
wire through the gallbladder and dilating the formed tract
through which a double pigtail plastic, self-expandable metal,
or lumen-apposing metal stent (LAMS) is placed. LAMS has
been reported to allow for better tissue apposition and lower
the rate of stent migration. Due to its larger diameter, it is also
associated with improved patency and allows for easier stone
extraction. Certain considerations should be appreciated
while planning EUS-GBD to ensure long-term patency of
stents. For example, transduodenal access through EUS-GBD
may interfere with subsequent cholecystectomy in cases of
interval EUS-GBD while transgastric EUS-GBD may be more
prone to stent dislocation or migration due to gastric motility.
Seminars in Interventional Radiology Vol. 37 No. 1/2020
18 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
Given the nature of the procedure, abdominal pain which may
reflect pneumoperitoneum, biliary peritonitis, or stent migra-
tion should be assessed.
A recent meta-analysis by Luk et al comparing 206 and
289 EUS-GBD and PT-GBD patients, respectively, found
similar rates of technical and clinical success between the
two procedures.26
Acute Cholangitis
Acute cholangitis is the result of obstruction and subsequent
infection of biliary ductal system. When frank pus is present
within the biliary system, this is referred to as acute suppu-
rative cholangitis.
Etiology
Obstruction can be due to various etiologies with choledocho-
lithiasis accounting for nearly two-thirds of cases. Stones within
the gallbladder neck or cystic duct can also compress the
common bile duct (Mirizzi syndrome). Other causes include
malignant obstruction (24%), benign biliary strictures (4%),
sclerosing cholangitis (3%), or even Lemmel’s syndrome in
which a duodenal diverticulum compresses the ductal opening
into the duodenum.
Bacterial infection of bile most commonly results from
ascending migration of pathogens from gastrointestinal
tract.27 Decreased biliary flow secondary to obstruction allows
ascent of bacteria from duodenum—also referred to as ascend-
ing cholangitis. The higher positive bile duct culture rates in
partial obstruction compared with complete obstruction is
consistent with this pathophysiology.28 Infection can also be
iatrogenic in nature following endoluminal or percutaneous
instrumentation. The presence of a biliary stent itself increases
risk of bacteremia. For this reason, routine exchange every
3 months is recommended. Bacterial translocation from the
portal venous or lymphatic system is also a possible, though
less likely, mechanism.
The most common pathogen in cholangitis is E. coli. In the
case of cholangitis associated with indwelling stents, Entero-
coccus is more commonly seen. Other pathogens include
Klebsiella and Pseudomonas aeruginosa.29
If left untreated, obstruction and infection of the biliary
tract may lead to biliary sepsis, systemic inflammatory
response syndrome (SIRS), and even death. As intraductal
pressure increases with production of bile in the setting of
obstruction, there is disruption of junctions between hepatic
cellular architecture which, in turn, leads to bacteria entering
the bloodstream. Bile secreted at pressures of 12 to 15 cm
H2O and normal extrahepatic biliary ductal pressure is 10 to
15 cm H2O which is regulated by sphincter of Oddi. Normally,
continuous antegrade flow of bile keeps biliary tree sterile.
However, when pressure exceeds 25 cm H2O, cholangiove-
nous reflux develops.
Diagnosis
Acute cholangitis is classically characterized by fever, right
upper quadrant pain, and jaundice—aka Charcot’s triad. This
combination, first described in 1877, has a high specificity
Seminars in Interventional Radiology Vol. 37 No. 1/2020
Navuluri et al.
but a low sensitivity for diagnosis cholangitis. Of the three
symptoms, pain and fever are more common features than
jaundice. Reynold’s pentad, coined in 1959, is composed of
Charcot’s triad plus altered mental state and septic shock.
However, it is present in only 3.5 to 5.1% of patients.30–32
Patients typically present with leukocytosis as well as labo-
ratory evidence of cholestasis including elevated direct biliru-
bin, alkaline phosphatase, and GGT. Of these three markers,
alkaline phosphatase is the most consistently elevated.33 Alka-
line phosphatase is also useful to monitor posttreatment, as it
has a relatively quicker recovery pattern after decompression
and is thus a more accurate indicator of adequate drainage. One
promising laboratory marker currently being studied is procal-
citonin. There is evidence that it is a more accurate marker of
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severe disease and can better indicate need for emergent
decompression.34
The Tokyo Guidelines, originally published in 2007 and
subsequently revised in 2013 and 2018, were created to
more definitely delineate the diagnostic criteria, grading, and
management of acute cholangitis. Diagnostic criteria are
based on clinical or laboratory evidence of systemic inflam-
mation, cholestasis, and findings on imaging. A study of the
TG13 criteria allowed for accurate diagnosis in 90% of cases.35
The Tokyo Guidelines also score the severity of disease from
grade I to III based on age and the presence of leukocytosis,
fever, hyperbilirubinemia, and hypoalbuminemia. Patients
with grade I disease meet none of the aforementioned
criteria, while grade III is defined by the presence of organ
dysfunction. The guidelines go even further and provide a
management flowchart which recommends early drainage
in grade II disease, and urgent decompression grade III
disease. A secondary benefit to treating patients with early
biliary drainage, regardless of severity of disease, is shorter
hospital stays.36
Imaging
The goal of imaging is to determine not only the presence of
obstruction but also the cause and level of obstruction.
Additionally, it is important to identify complications such
as abscess, portal vein thrombosis, suppurative cholangitis,
and biliary peritonitis.
Ultrasound can be used to identify gallbladder stones and
ductal dilatation. The normal diameter of the common bile
duct varies based on age and a history of prior surgery. If
there is no history of cholecystectomy, a normal CBD meas-
ures 6 to 8 mm. The intrahepatic bile ducts should not exceed
2 mm in diameter or 40% of the caliber of the accompanying
portal vein branch. Even in experienced hands, ultrasound
has poor sensitivity in detecting CBD stones (<30%). This is
due, in part, to the difficulty in visualizing the entire CBD.37
CT is not much better at identifying biliary stones and has
been reported to detect stones within the biliary tree in only
42%.38 This is due in part to the fact that only 20% of stones are
hyperattenuating and up to 24% are isoattenuating relative to
bile. On the other hand, CT is quite effective in characterizing
ductal dilatation, as well as complications of cholangitis includ-
ing hepatic abscess and pneumobilia.28 Additional CT findings
of acute cholangitis include hyperdense areas on arterial phase
 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
imaging (transient hepatic attenuation differences) and peri-
biliary edema which reflect inflammation resulting from
obstruction. This latter finding has relatively high sensitivity
but low specificity in identifying acute cholangitis.39
MRI and MRCP have limited utility in the acute setting but
can be helpful in evaluating complications of cholangitis, such
as vascular thrombosis and hepatic abscess, or any underlying
mass that may be causing biliary obstruction. MRI findings can
include biliary ductal dilatation, increased T2 signal in around
infected ducts, peribiliary parenchymal enhancement, as well
as ductal wall thickening and enhancement. MRCP can detect
ductal pathology in acute cholangitis in over 80% of cases.
Findings include ragged duct appearance or periductal signal
differences. It has limited sensitivity in detecting stones,
however.40
Management
Treatment of acute cholangitis can be boiled down to intrave-
nous (IV) antibiotics and decompression; antibiotics target the
bacterial pathogens, while decompression addresses the
underlying obstruction. To be more specific, the goal of anti-
biotics is to control inflammation, prevent sepsis, as well as
limit complications like intrahepatic abscess formation. If there
is no response to antibiotics or sepsis develops, then urgent
biliary decompression should be performed. However, since
the most important predisposing factor to acute cholangitis is
biliary obstruction, drainage is often necessary. There are
several options for biliary decompression with the most com-
mon being endoscopy (ERCP) and percutaneous transhepatic
biliary drainage (PTBD). Choice of technique depends on local
expertise, level of obstruction, and other individual patient
factors.
ERCP is considered the first-line therapy. It is less invasive
compared with PTBD in the sense that it allows for traversal of
existing orifices rather than creating an artificial tract. Obstruc-
tion can be managed via either biliary stenting or nasobiliary
tube placement. The latter allows for monitoring of bile output.
Plastic stents (7–10 Fr) on the other hand are more comfortable
for patients as there is no external drainage. The downside of
internal stents is that they are more likely to be occluded with
biofilm and sludge and replacement is more invasive than for
an internal–external percutaneous drain. Aggressive maneu-
vers such as sphincterotomy or stone extraction can also be
performed in the same setting, though should be avoided in
severe acute cholangitis per the Tokyo Guidelines. Complica-
tions of endoscopic therapy can include pancreatitis, hemor-
rhage, bowel perforation, stent occlusion or migration, and
injury to the bile ducts including perforation. ERCP is generally
not an option in patients with altered surgical anatomy; though
present in some centers, balloon enteroscopy-assisted ERCP
requires special equipment and expertise, and is technically
challenging and time consuming.
Percutaneous drainage is generally considered the second-
line treatment option after failed ERCP except in patients with
surgically altered anatomy (e.g., Roux-en-Y) not amenable to
endoscopy. PTBD may also be more advantageous for obstruc-
tions above the CBD when drainage of individual lobes or
segments is sought. Internal–external or external-only drains
Navuluri et al. 19
can be uncomfortable and a cosmetic issue for some patients.
Additionally, they can be associated with bile leakage and skin
inflammation. As with plastic stents, routine exchanges of
percutaneous drains are necessary, but they are quicker and
less invasive.
Preprocedure
The SIR Standards of Practice guidelines categorize biliary
interventions as a high bleeding risk. INR and platelet thresh-
olds are defined as
1.8 and <50  109/L, respectively.41
However, coagulopathy is a relative contraindication, and
urgency for correction depends on the clinical status of the
patient. In theory, IV antibiotics should have already been
initiated prior to any intervention as part of the medical
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management.
As with any procedure, review of imaging is imperative
before putting needle to skin. First, any anatomic limitations
should be assessed. These can include interposed bowel
(Chilaiditi syndrome), low diaphragmatic recess, or ascites.
Ascites is a relative contraindication and may be overcome by
performing a preprocedure paracentesis or, in some cases, by
drainage of left-sided hepatic ducts which are less likely to be
surrounded by dependent ascites.
Drainage should target the lobe or segment with the
greatest degree of ductal dilation. If obstruction is central
and involves both lobes, a right-sided PTBD is often preferred
as it drains the greatest amount of functional hepatic paren-
chyma. The downside of right-sided access is that intercostal
catheter placement is associated with more pain and discom-
fort, and a greater risk of catheter migration with respiratory
motion. Left-sided biliary drains, on the other hand, offer the
benefit of lower risk of catheter migration, lower risk of pleural
transgression, and greater patient comfort. However, they can
also be technically more challenging as the subxiphoid win-
dow to access the left lobe is relatively small and there is
greater radiation exposure for the interventionalist. Upon
placement of the drain, cholangiography can assess whether
there is communication between the ducts of the right and left
lobe and consequently the need for bilobar drainage. Bilateral
right- and left-sided drains may be necessary for Klatskin
tumors. Lastly, keep in mind that drainage of a nondilated
biliary system may occasionally be indicated in some patients
with acute cholangitis including some cases of biliary leakage.
Procedure
With the patient in a supine position on the angiography table,
the intrahepatic biliary tree should be first interrogated with
ultrasound to identify a peripheral duct to target. A puncture
site in the midaxillary line and caudal to the costophrenic
angle is selected. Ideally, the puncture site is chosen during
inspiration to further limit risk of pleural transgression. A good
rule of thumb for right-sided PTBD is to target the 10th
intercostal space or lower. After administration of local anes-
thetic, a 21-gauge needle (Accustick; Boston Scientific, Marl-
borough, MA) is advanced under ultrasound guidance into the
targeted duct. Care should be taken to advance the needle over
the rib to avoid injury to an intercostal artery. A peripheral duct
is preferred to maximize landing zone of the biliary drain as
Seminars in Interventional Radiology Vol. 37 No. 1/2020
20 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
well as to reduce risk of arterial or portal injury. Upon access of
the duct, the inner stylet is removed. In an obstructed system,
viscous bile will slowly drip from the needle and serve as visual
confirmation of appropriate access. If a left-sided PTBD is
planned, it is preferable to target segment 3, as segment 2
may be too cranial to access via a subxiphoid approach. It can
also be unnerving to be working in close proximity to the heart.
If an intrahepatic duct cannot be targeted with ultrasound
guidance, the needle is simply advanced cephalad toward the
T12 vertebral body. The inner stylet is removed and a small
amount of dilute contrast is gently injected as the needle is
withdrawn until a duct is opacified. Excessive injection of
contrast outside the target duct may obscure the field of view
and hinder subsequent access attempts. Additionally, over-
injection of an obstructed system may induce biliary sepsis.
Effort should be made to minimize the number of capsular
punctures to reduce the risk of bleeding. A two-stick tech-
nique—initial puncture risk of a central duct to opacify the
biliary tree and allow for a second puncture into a peripheral
duct—should be an option of last resort as it risks vascular
injury including arteriovenous fistula and hemorrhage.
In the setting of an obstructed biliary ductal system,
contrast within ducts will appear static, though in the case
of partial obstruction slow drainage toward the hilum may be
visualized. Care should be taken not to overdistend the ductal
system with contrast to limit the risk of biliary sepsis. If the
duct is dilated, bile can first be aspirated to decompress the
system prior to performing a cholangiogram. It is important
to note which ducts are not opacifying and to correlate the
findings with preprocedure imaging. Nonvisualization of
portions of the biliary tree may indicate segments that are
not being adequately drained.
Once fluoroscopic confirmation of biliary ductal access is
obtained, a 0.018″ wire is advanced into the ductal system
centrally. We prefer using a V18 wire (Boston Scientific)
because of its hydrophilic tip. This facilitates placement into
a peripheral duct should the needle not be well seated, and
also aids in crossing any downstream obstruction. Addition-
ally, the greater stiffness of the wire eases advancement of
the 5-Fr Accustick sheath/dilator assembly. A hydrophilic
0.035″ wire and angled 5-Fr angiographic catheter can also
be used to cross the central obstruction once the introducer
system has been placed.
A Super Stiff Amplatz wire is preferred for tract dilatation
and final placement of an 8.5-Fr internal–external biliary
drain. Care should be taken to ensure that the radiopaque
marker, which indicates the location of the last side hole, is
positioned appropriately to span the obstruction and does not
extend outside the liver parenchyma to avoid bile leakage and
peritonitis. Plastic Cotton-Leung stents can be placed percuta-
neously but requires placement of a sheath which involves
unnecessary manipulation in the setting of acute cholangitis.
There is no role for primary stenting in the setting of acute
cholangitis.
If the central obstruction cannot be crossed easily, aggres-
sive or lengthy wire manipulation is not undertaken for fear of
precipitating biliary sepsis. Moreover, the primary goal should
be decompression of the biliary system rather than addressing
Seminars in Interventional Radiology Vol. 37 No. 1/2020
Navuluri et al.
the obstruction itself. In these cases, an external drain (Daw-
son-Mueller; Cook, Bloomington, IN) is placed with the pigtail
positioned in a central duct. The patient is then scheduled to
return in 3 to 7 days for conversion to an internal–external
biliary drain (►Fig. 3). The interval time allows for improve-
ment in periductal inflammation and edema by decompressing
the obstructed biliary system and giving time for IV antibiotics
to work. This typically makes the subsequent crossing of
the obstruction much easier. If there is still resistance in
advancing the drainage catheter across the obstruction, gentle
angioplasty—just enough to allow passage of drain—can be
considered, though care must be taken to avoid bile duct
rupture. Alternatively, consider advancing the drain over a stiff
hydrophilic wire. External drains are not ideal, as they are more
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prone to dislodgment, and result in fluid and electrolyte
losses. Regardless of type, the drain should be left open to a
drainage bag until resolution of the acute cholangitis. Finally,
bile culture with Gram stain should be performed to better
tailor the antibiotic regimen.
Postprocedure
Instrumentation of the biliary tract can lead to the release of
bacteria and endotoxins into the bloodstream with subse-
quent development of fever, chills, rigors, and even shock.
This is most commonly seen immediately following the
procedure. Rigors can be controlled with 25 to 50 mg meper-
idine IV along with a dose of broad-spectrum antibiotics (e.g.,
1.5–3 g ampicillin–sulbactam IV). Blood cultures should be
drawn and ICU admission should be strongly considered for
management of sepsis.
Regular flushing of the biliary drain should be performed
to clear biliary sludge/debris and clot. Aspiration of the drain
should be avoided, as it will invariably draw up enteric
contents and flora into the biliary system.
Complications
Complications of PTBD include bleeding, vascular injury, bile
leak, biloma, peritonitis, sepsis, pancreatitis, and pleural
transgression. The reported major complication rate is
2%.42 Bleeding may result from either capsular or parenchy-
mal injury to the liver. Potential vascular injuries include
arterial pseudoaneurysm or vascular-biliary fistulae which
can present as hemobilia (►Fig. 4). Management of hemo-
bilia generally depends on the sources of bleeding (hepatic
artery, hepatic vein, or portal vein). Treatment options range
from tamponading the site of injury in cases of venous injury
to embolization in cases of arterial injury.
Pain at the site of puncture can be particularly uncom-
fortable for patients with right-sided drains due to the fact
that they traverse the intercostal space and may shift in
position with each respiration. Right-sided drains are also at
greater risk of hemothorax or pneumothorax, given the
potential for crossing the pleural space.
Outcomes
The technical success rates of percutaneous drainage depend
on the local protocol (ERCP vs. PTBD) for the types of obstruc-
tions, as well as operator expertise, though are generally
 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
Fig. 3 A 46-year-old male with acute cholangitis presenting with elevated
serum bilirubin, leukocytosis, and jaundice. (a) CT abdomen with severely
dilated interhepatic biliary ductal system within the left hepatic lobe
(arrow) secondary to an obstructing central mass (cholangiocarcinoma). (b)
Initial cholangiogram demonstrates markedly dilated ducts. The obstruction
could not be crossed and an external drain was left in place. Arrow: right-sided
internal–external drain. (c) One week later, there is improvement in left lobe
ductal dilatation and successful placement of an internal–external biliary
drain. Arrow: right-sided internal–external drain.
reported to be over 90%. Some studies have shown no differ-
ence in success between dilated and nondilated biliary ducts.
However, the complication rates are roughly double in the
latter group.43,44
Navuluri et al. 21
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Fig. 4 A 66-year-old male who underwent percutaneous transhepatic
biliary drainage placement 2 weeks earlier presented with bright red
blood per rectum and a slowly downtrending hemoglobin. CT of the
abdomen shows the internal–external biliary drain (arrow) in com-
munication with a left portal vein branch, suggesting a portal-biliary
fistula as the cause of hemobilia.
Alternative Procedures
Although ERCP continues to be considered first line for
biliary duct drainage, alternative procedures including per-
cutaneous transhepatic and endoscopic ultrasound-guided
biliary drainage, transgastric or transjejunal ERCP, and lapa-
roscopic common bile duct exploration are considered in
certain instances.
EUS-BD is increasingly being used as an alternative method
to ERCP and PTBD for providing a minimally invasive option for
biliary drainage in cases where ERCP has failed, in patients with
surgically altered anatomy in which access to the ampulla is not
possible, or in cases of occluded transpapillary-placed stents.
Contraindications for this procedure include coagulopathy,
ascites, and interposed vessels. Varying approaches of EUS-BD
exist including EUS-guided hepaticogastrostomy (EUS-HGS)
through an intrahepatic approach and EUS-guided hepatico-
duodenostomy (EUS-HDS). In EUS-HGS, puncture of one of the
left hepatic ducts is achieved under EUS guidance through
either the cardia or lesser curvature of the stomach. Once access
is gained, a fistula is dilated using a coaxial electric cautery,
bougie dilator, and/or balloon through which a stent is placed.
While EUS-HGS has been seen to be a safe and effective
alternative option for biliary drainage, a recent study by Nakai
et al evaluating the safety and efficacy of EUS-HGS in patients
with malignant biliary obstruction found that 8/33 (24%)
patients experienced recurrent biliary obstruction after a
median of 4.5 months, six of which was due to hyperplasia of
the uncovered portion of the stent.45 Another limitation of this
technique is that in proximal obstructions, the right-sided
biliary system remains undrained. Thus, additional procedures
may be necessary to drain both systems such as placing a bare
metal stent connecting the left and right biliary systems or EUS-
HDS. However, use of EUS-GBD of isolated right intrahepatic
ductal obstruction has been described as a relatively safe and
feasible alternative after failed ERCP.46 EUS-HDS involves
Seminars in Interventional Radiology Vol. 37 No. 1/2020
22 Emergent Treatment of Acute Cholangitis and Acute Cholecystitis
gaining access into the right hepatic duct by forming a fistula
through the duodenum by using a stent. Data directly compar-
ing EUS-BD with PTBD are limited. One study by Khashab et al
retrospectively compared outcomes of 73 patients with distal
malignant biliary obstruction (EUS-BD ¼ 22, PTBD ¼ 51) and
found that while technical success rate was higher for PTBD
(100 vs. 86.4%), the clinical success rate was similar (92.2 vs.
86.4%, p ¼ 0.40).47 A meta-analysis by Sharaiha et al including
483 patients from nine studies (EUS-BD ¼ 252, PTBD ¼ 231)
found that technical success was similar between the two
procedures (OR, 1.78; 95% CI, 0.69–4.59) and EUS had better
clinical success rates than PTBD (OR, 0.45; 95% CI, 0.23–0.89).48
Due to the advent of these minimally invasive options for
biliary drainage, open or laparoscopic bile duct exploration
(LBDE) and stone removal are infrequently performed. How-
ever, in patients undergoing laparoscopic cholecystectomy,
transcystic or transductal LBDE has been considered an
appropriate technique for common bile duct stone removal
in cases of nonsevere acute cholangitis.49 Once access is
gained through an incision exposing either the cystic or
common bile duct, a cholangiogram catheter is introduced
to visualize any stones using fluoroscopy. Depending on the
location and size of the stone seen, a 4-Fr Fogarty balloon can
be used to clear stones into the duodenum, or in more
difficult cases, laser ablation or retrieval basket through a
choledochoscope may be utilized after access is dilated.
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