What are the Tokyo Guidelines (TG) for the diagnosis and treatment of acute cholangitis and cholecystitis?

From the Guidelines

The Tokyo Guidelines recommend a standardized approach for managing acute cholangitis and cholecystitis, emphasizing early intervention and severity-based treatment. The guidelines provide a grading system to stratify severity and guide the timing of intervention, with severe (grade 3) acute cholangitis requiring urgent decompression, moderate (grade 2) acute cholangitis requiring early decompression, and mild (grade 1) acute cholangitis being initially observed on medical treatment 1.

Key Points of the Tokyo Guidelines

• Diagnosis: Uses a combination of clinical symptoms, laboratory tests, and imaging findings to diagnose and grade severity of acute cholangitis and cholecystitis.
• Severity grading: Classifies cases as Grade I (mild), Grade II (moderate), or Grade III (severe) based on specific criteria.
• Treatment recommendations:
  • For acute cholangitis:
    • Mild: Antibiotics (e.g., ceftriaxone 1-2g IV daily) and biliary drainage if no response
    • Moderate/Severe: Immediate biliary drainage and antibiotics, with endoscopic retrograde cholangiopancreatography (ERCP) being the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1
  • For acute cholecystitis:
    • Mild: Early laparoscopic cholecystectomy
    • Moderate/Severe: Gallbladder drainage (e.g., percutaneous transhepatic gallbladder drainage) followed by delayed cholecystectomy
• Antibiotic therapy: Recommends empiric broad-spectrum antibiotics based on severity and local resistance patterns, typically covering Enterobacteriaceae and anaerobes.
• Timing of intervention: Emphasizes early intervention for better outcomes, especially in severe cases, with a multicenter case series evaluating the benefit of early biliary drainage on the 30-day mortality of patients presenting with acute cholangitis 1.

Treatment Approach

The guidelines emphasize the importance of early intervention, with immediate biliary drainage and antibiotics being recommended for moderate to severe acute cholangitis. ERCP is the preferred method for biliary decompression, with percutaneous transhepatic cholangiography (PTC) being reserved for patients in whom ERCP fails 1. Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1.

Severity-Based Treatment

The guidelines provide a severity-based approach to treatment, with mild acute cholangitis being initially observed on medical treatment, and moderate to severe cases requiring immediate intervention. The severity grading system helps guide the timing of intervention, with severe cases requiring urgent decompression and moderate cases requiring early decompression 1.

Antibiotic Therapy

The guidelines recommend empiric broad-spectrum antibiotics based on severity and local resistance patterns, typically covering Enterobacteriaceae and anaerobes. Antibiotic therapy should be initiated promptly, with the choice of antibiotic being guided by local resistance patterns and severity of disease 1.

Timing of Intervention

The guidelines emphasize the importance of early intervention, with early biliary drainage being associated with improved outcomes in patients with acute cholangitis. A multicenter case series evaluating the benefit of early biliary drainage on the 30-day mortality of patients presenting with acute cholangitis found significantly lower 30-day mortality in grade 2 acute cholangitis treated with early biliary drainage as compared to those who had more delayed drainage 1.

From the Research

Overview of Tokyo Guidelines

The Tokyo Guidelines (TG) are a set of criteria for the diagnosis and treatment of acute cholangitis and cholecystitis. The guidelines were first published in 2007 (TG07) and updated in 2013 (TG13) 2. The updated guidelines improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice.

Diagnostic Criteria

The diagnostic criteria for acute cholangitis include the presence of Charcot's triad (fever and/or chills, abdominal pain, and jaundice) and laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction 3. The TG13 criteria have a higher sensitivity (91.8%) compared to TG07 (82.8%) and Charcot's triad (26.4%) 4.

Severity Assessment

The severity of acute cholangitis can be classified into three grades: mild (grade I), moderate (grade II), and severe (grade III) 3. The severity assessment criteria in TG13 are based on two clinical factors: the onset of organ dysfunction and the response to initial medical treatment. Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors derived from recent literature 4.

Management

The management of acute cholangitis and cholecystitis includes medical treatment, biliary drainage, and surgical intervention. The TG13 guidelines provide flowcharts for the management of acute cholangitis and cholecystitis, and recommend medical care, gallbladder drainage, and antimicrobial therapy based on the severity of the disease 2.

Limitations

The Tokyo Guidelines may not be applicable to all cases of acute biliary pancreatitis, as the clinical picture of biliary acute pancreatitis can overlap with the diagnosis of cholangitis and cholecystitis, leading to significant antibiotic and endoscopic retrograde cholangiopancreatography (ERCP) overuse 5. Therefore, the guidelines should be used with caution in these cases, and further studies are needed to develop specific diagnostic criteria for acute biliary pancreatitis.

Key Points

• The Tokyo Guidelines (TG) are a set of criteria for the diagnosis and treatment of acute cholangitis and cholecystitis.
• The TG13 criteria have a higher sensitivity and specificity compared to TG07 and Charcot's triad.
• The severity assessment criteria in TG13 are based on two clinical factors: the onset of organ dysfunction and the response to initial medical treatment.
• The management of acute cholangitis and cholecystitis includes medical treatment, biliary drainage, and surgical intervention.
• The guidelines may not be applicable to all cases of acute biliary pancreatitis, and further studies are needed to develop specific diagnostic criteria for this condition 2, 3, 4, 5.