Synopsis
Relieve cholestatic itch safely, recognise infected obstruction before shock, prescribe complete initial treatment, secure biliary source control, and support nutrition, sleep and patient-led escalation.
- Cholestatic pruritus often worsens at night and may cause excoriation, insomnia, low mood and poor function; measure its severity and effect rather than relying on bilirubin level.
- Look for reversible obstruction first. Drainage may relieve itch in mechanical blockage, while colestyramine requires bile acids to reach the intestine and is ineffective in complete biliary obstruction.
- A licensed adult pruritus regimen is colestyramine 4 g orally once daily, increasing to 4 g twice daily if needed; mix each sachet with liquid and separate other medicines by at least one hour before or four to six hours after.
Key red flags
Hypotension, altered mental state, oliguria, hypoxaemia, mottling or rising lactate with suspected cholangitis indicates high-risk sepsis and possible critical-care need.
Fever or rigors after ERCP or biliary stenting suggests device blockage or an infected undrained sector and requires immediate reassessment.
Progressive jaundice with intractable itch, weight loss or pale stools requires structural and cancer evaluation; symptomatic treatment alone is incomplete.
Confusion, low blood pressure, low urine output, hypoxaemia or lactate rise marks severe sepsis and accelerates drainage and critical-care review.
Reasoning priorities
Identify hypoperfusion and immediate organ threat and guide repeated response assessment.
Normal initial blood pressure does not exclude evolving sepsis; trend mental state, urine output, capillary refill, respiratory status and lactate.
Worked reasoning
A 76-year-old with a metal stent for distal cholangiocarcinoma has rigors, confusion, BP 84/52 mmHg, lactate 3.8 mmol/L, bilirubin 164 micromol/L and new duct dilatation above the stent. CrCl is 38 mL/min, co-amoxiclav was taken eight days ago, and there is no beta-lactam allergy or previous co-amoxiclav-associated hepatic injury.
- Recognise high-risk stent-cholangitis sepsis and take blood cultures without delaying antibiotics beyond one hour. Age over 65 plus co-amoxiclav in the preceding two weeks selects the DBTH piperacillin/tazobactam branch: give 4.5 g IV every eight hours over 30 minutes, within the selected product maximum for CrCl 20–40 mL/min, while arranging urgent drainage.
- Give 250 mL balanced isotonic crystalloid over 10–15 minutes; after each bolus reassess pressure, lungs, capillary refill and urine output, stopping at 750 mL when perfusion improves rather than automatically infusing a fixed large volume.
- Urgent ERCP demonstrates tumour ingrowth and pus above the occluded stent; the endoscopist clears debris and places a new internal stent that restores bile flow.
- After ERCP, lactate falls to 1.6 mmol/L within 24 hours and mentation/urine output normalise. Blood and bile grow co-amoxiclav-susceptible E. coli. At 72 hours the patient is afebrile, absorbs tablets and CrCl has recovered to 55 mL/min; the infection team stops piperacillin/tazobactam and selects co-amoxiclav 500/125 mg orally every eight hours with food to complete seven days total. Falling bilirubin and sustained recovery support stopping at that review point; recurrent fever triggers renewed drainage assessment.