Tokyo Guidelines for Acute Cholangitis 2018

Tokyo Guidelines 2018 Cholangitis

A — Systemic Inflammation

Fever (>38°C / 100.4°F)

Chills/Rigors

Elevated Inflammatory Markers (CRP/WBC)

B — Cholestasis

Jaundice

Abnormal Liver Function Tests

C — Imaging

Biliary Dilation

Evidence of Etiology (Stone, Stent, Stricture)

Severity — Grade II (Moderate) Features

Abnormal WBC (<4,000 or >12,000)

High Fever (≥39°C / 102.2°F)

Age ≥75 Years

Bilirubin ≥5 mg/dL

Hypoalbuminemia (<0.7 × LLN)

Severity — Grade III (Severe) Features

Cardiovascular Dysfunction

Neurological Dysfunction

Respiratory Dysfunction

Renal Dysfunction

Hepatic Dysfunction (PT-INR >1.5)

Hematological Dysfunction (Platelet <100,000)

Diagnosis: –

Awaiting input

Select all relevant criteria.

Provides diagnostic criteria and severity grading for acute cholangitis.

Why Use

Objectively guides diagnosis and management of patients with acute cholangitis in terms of timing and need for biliary drainage and supportive care. Charcot’s triad (fever, right upper quadrant pain, jaundice) has high specificity but low sensitivity for acute cholangitis ( Kiriyama et al 2017 ).

When to Use

Use in patients with suspected acute cholangitis (i.e., fever, jaundice, right upper quadrant pain, altered mental status, and/or hemodynamic instability).

Formula

Patient must have a suspected diagnosis (≥1 item in A + ≥1 item in B or C) or definite diagnosis (≥1 item in A, B, and C) to meet entry criteria for severity grading, see table below: Diagnosis: Criteria Part A Systemic inflammation Fever (>38°C/100.4°F) and/or shaking chills Laboratory data: evidence of inflammatory response (WBC <4 or >10 x1,000/μL and/or CRP ≥1 mg/dL) Part B Cholestasis Jaundice (total bilirubin ≥2 mg/dL) Laboratory data: abnormal liver enzymes (ALP, γGTP, AST, ALT levels >1.5 x STD) Part C Imaging Biliary dilatation Evidence of the etiology on imaging (stricture, stone, stent, etc.) Severity grading: Grade III (dysfunction in ≥1 of the following): Cardiovascular dysfunction: hypotension requiring dopamine ≥5 μg/kg per min or any dose of norepinephrine Neurological dysfunction: disturbance of consciousness Respiratory dysfunction: PaO₂/FiO₂ ratio <300 Renal dysfunction: oliguria or creatinine >2.0 mg/dL Hepatic dysfunction: PT‐INR >1.5 Hematological dysfunction: platelet count <100,000/mm ³ Grade II (≥2 of the following conditions): Abnormal WBC count (>12,000/mm³ or <4,000/mm³) High fever (≥39°C/102.2°F) Age ≥75 years Hyperbilirubinemia (total bilirubin ≥5 mg/dL) Hypoalbuminemia (<0.7 x upper limit of normal) Grade I Does not meet the criteria of Grade III or Grade II acute cholangitis at initial diagnosis

Pearls / Pitfalls

More extensively studied in non-US populations. Conditions such as acute hepatitis and acute cholecystitis may have some similarities in presentation and should be ruled out. Although MRI and MRCP have the highest sensitivity/specificity for bile duct dilation, abdominal US followed by CT abdomen are more readily available and cost-effective, and thus should be performed initially. Procalcitonin is useful in assessing the severity of cholangitis, not in the diagnosis. For patients with grade II-III (moderate to severe) cholangitis, transfer to a hospital that can perform biliary drainage and provide ICU level care is recommended.

Management

Upon diagnosis of acute cholangitis (regardless of severity) initial treatment generally consists of antibiotics, fluid resuscitation, electrolyte repletion, and appropriate analgesic administration. Grade I (mild): In most cases, initial treatment as above is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment within 24 hrs. Grade II (moderate): Early (within 48 hrs of admission) endoscopic or percutaneous transhepatic biliary drainage is indicated. Grade III (severe): Treat underlying sepsis aggressively with respiratory (tracheal intubation) and circulatory (pressors) support. Emergent (as soon as patient is hemodynamically stable) endoscopic or percutaneous transhepatic biliary drainage is indicated.

Advice

If a definitive diagnosis cannot be made on presentation, it is reasonable to reassess the patient using the diagnostic criteria every 6-12 hrs. In patients with grade I (mild) disease, if no response to the initial treatment is observed within 24 hr, perform biliary drainage immediately. In patients with grade II (moderate) or grade III (severe) disease, perform biliary drainage as soon as possible along with supportive care and antibiotics. Also, obtain blood cultures and bile cultures in such patients. Consider treating the etiology of acute cholangitis with endoscopic (endoscopic sphincterotomy or choledocholithotomy), percutaneous, or operative intervention once the acute illness has resolved. Cholecystectomy should be performed for gallstones after the acute cholangitis has resolved. Antibiotics should be chosen based on severity of disease, location of infection (community or hospital acquired), and local susceptibilities (see Tokyo Guidelines 2018 Antimicrobial Therapy for Acute Cholangitis and Cholecystitis ).

More Information

Interpretation: Grade Acute cholangitis severity Recommendations I Mild Antibiotics and general supportive care; consider biliary drainage if no response to initial treatment II Moderate Antibiotics and general supportive care; early endoscopic or percutaneous transhepatic biliary drainage is indicated III Severe Initial treatment with antibiotics, urgent biliary drainage, appropriate respiratory/circulatory management