Management of acute cholangitis

Endoscopic sphincterotomy (ES) is the treatment of choice for patients with (severe) acute cholangitis. For fit patients without co-morbidity with mild cholangitis and CBD stones with a gallbladder in situ, the one-stage laparoscopic approach could be considered as an alternative in centers with sufficient experience. The results of both procedures are comparable. Open surgery is relatively safe. It has a high success rate, good/excellent long-term results, but is not very attractive for the patient and should not be used routinely nowadays. Therefore, the indication should be limited for management of severe complications after ES as perforations of the duodenum, large CBD stones and patients with Mirizzi's syndrome or intrahepatic stones with stenosis of the bile duct. ES as primary treatment for CBD stones should be followed by laparoscopic cholecystectomy in 'fit' patients. In patients with malignant disease, particularly after repeated stent failure and subsequent cholangitis, bypass surgery should be considered in patients with a life expectancy of >3 months.