How should I approach the management of a patient with PSC who presents with recurrent cholangitis?

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 ¹ (Silveira and 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 ¹ (Gordon, 2006). ERCP with stenting or balloon dilatation can reduce episodes of cholangitis and improve bile flow, thus preventing further infections (Sedki and 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 ¹ (Silveira and Lindor, 2008). Antibiotic prophylaxis may be considered in patients with frequent episodes, although evidence is limited and should be individualized (Sedki and Levy, 2018). Additionally, ursodeoxycholic acid is sometimes used to improve liver biochemistry but has not been definitively shown to reduce cholangitis episodes ¹.

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 ¹ (Gordon, 2006; Silveira and Lindor, 2008; Sedki and Levy, 2018).