Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis

Diagnosis of Acute Cholangitis

Acute cholangitis is typically diagnosed based on clinical presentation, laboratory tests, and imaging studies. The Tokyo Guidelines propose the following diagnostic criteria:

Diagnostic Criteria

• A. Systemic Inflammation
  • Fever and/or shaking chills, or evidence of an inflammatory response (e.g., abnormal white blood cell count, C-reactive protein).
• B. Cholestasis
  • Jaundice, or abnormal liver function tests indicative of cholestasis (e.g., elevated alkaline phosphatase, gamma-glutamyl transpeptidase, or bilirubin levels).
• C. Imaging
  • Evidence of biliary dilatation on imaging, or the presence of an etiology such as a stone, stricture, or stent.

To establish a diagnosis, the presence of one item in each of the above categories (A + B + C) is required.

Severity assessment criteria for acute cholangitis

Grade III (severe) acute cholangitis
Onset of dysfunction at least in any one of the
following organs/systems:
-Cardiovascular dysfunction: hypotension requiring dopamine ≥5 lg/kg per min, or any dose of norepinephrine
-Neurological dysfunction: disturbance of consciousness
-Respiratory dysfunction: PaO2/FiO2 ratio <300
-Renal dysfunction: oliguria, serum creatinine >2.0 mg/dl
-Hepatic dysfunction: PT-INR >1.5
-Hematological dysfunction: platelet count <100,000/mm3

Grade II (moderate) acute cholangitis
“Grade II” acute cholangitis is associated with any two of the following conditions:
-Abnormal WBC count (>12,000/mm3, <4,000/mm3)
-High fever (≥39°C)
-Age (≥75 years)
-Hyperbilirubinemia (total bilirubin ≥5 mg/dl)
-Hypoalbuminemia (<STD 9 0.7)

Grade I (mild) acute cholangitis
“Grade I” acute cholangitis does not meet the criteria of “Grade III (severe)” or “Grade II (moderate)” acute cholangitis at initial diagnosis
Cited from Kiriyama et al.

References:

Miura F, Okamoto K, Takada T, Strasberg SM, Asbun HJ, Pitt HA, Gomi H, Solomkin JS, Schlossberg D, Han HS, Kim MH, Hwang TL, Chen MF, Huang WS, Kiriyama S, Itoi T, Garden OJ, Liau KH, Horiguchi A, Liu KH, Su CH, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Endo I, Suzuki K, Yoon YS, de Santibañes E, Giménez ME, Jonas E, Singh H, Honda G, Asai K, Mori Y, Wada K, Higuchi R, Watanabe M, Rikiyama T, Sata N, Kano N, Umezawa A, Mukai S, Tokumura H, Hata J, Kozaka K, Iwashita Y, Hibi T, Yokoe M, Kimura T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40. doi: 10.1002/jhbp.509. Epub 2018 Jan 8. PMID: 28941329.