Management of a patient with primary sclerosing cholangitis (PSC) presenting with recurrent cholangitis should focus on prompt diagnosis and targeted treatment of biliary infections, alongside addressing the underlying biliary strictures that predispose to infection. Initial management involves confirming the diagnosis of cholangitis clinically and biochemically, followed by empirical broad-spectrum antibiotics tailored to cover common biliary pathogens, with adjustments based on culture results where possible NICE CKS Silveira & Lindor 2008. Supportive care including fluid resuscitation and monitoring for sepsis is essential.
Endoscopic intervention via endoscopic retrograde cholangiopancreatography (ERCP) plays a critical role in managing recurrent cholangitis in PSC by allowing biliary decompression and dilation of dominant strictures, which are often the nidus for infection NICE CKS Gordon 2006. ERCP with stenting or balloon dilatation can reduce episodes of cholangitis and improve bile flow, thus preventing further infections Sedki & Levy 2018. However, ERCP should be performed cautiously due to increased risk of procedure-related complications in PSC patients.
Long-term management includes regular surveillance for cholangiocarcinoma, which can present similarly to recurrent cholangitis, and consideration of liver transplantation in cases of advanced disease or refractory infections NICE CKS Silveira & Lindor 2008. Antibiotic prophylaxis may be considered in patients with frequent episodes, although evidence is limited and should be individualized Sedki & Levy 2018. Additionally, ursodeoxycholic acid is sometimes used to improve liver biochemistry but has not been definitively shown to reduce cholangitis episodes NICE CKS.
In summary, the approach integrates prompt antibiotic therapy, endoscopic management of strictures, vigilant surveillance for malignancy, and consideration of transplantation in advanced cases, reflecting both UK guideline recommendations and contemporary literature insights NICE CKS Gordon 2006Silveira & Lindor 2008Sedki & Levy 2018.
Key References
- CKS - Pancreatitis - chronic
- CKS - Pilonidal sinus disease
- CKS - Cholecystitis - acute
- NG104 - Pancreatitis
- NG78 - Cystic fibrosis: diagnosis and management
- (Gordon, 2006): Recurrent primary sclerosing cholangitis: Clinical diagnosis and long-term management issues.
- (Silveira and Lindor, 2008): Clinical features and management of primary sclerosing cholangitis.
- (Sedki and Levy, 2018): Update in the Care and Management of Patients with Primary Sclerosing Cholangitis.