What is the classification of acute cholangitis?

Classification of Acute Cholangitis

Acute cholangitis is classified into three grades according to the Tokyo Guidelines: Grade I (mild), Grade II (moderate), and Grade III (severe), based on severity assessment criteria that guide appropriate management and timing of biliary drainage.

Severity Classification System

The Tokyo Guidelines provide a standardized classification system for acute cholangitis based on severity:

• Grade III (Severe): Defined as acute cholangitis accompanied by at least one new-onset organ dysfunction 1, 2

• Grade II (Moderate): Defined as acute cholangitis that is unaccompanied by organ dysfunction but does not respond to initial medical treatment, with clinical manifestations and/or laboratory data not improving 1, 2

• Grade III (Mild): Defined as acute cholangitis that responds to initial medical treatment with improved clinical findings 2, 3

Clinical Implications of Classification

The classification directly impacts management decisions:

• Grade III (Severe): Requires urgent biliary decompression due to the presence of organ dysfunction 1

• Grade II (Moderate): Requires early biliary decompression (within 24-48 hours), as studies show significantly lower 30-day mortality when drainage is performed within 24 hours of admission 1

• Grade I (Mild): Can be initially observed on medical treatment with antibiotics, with elective drainage if needed 1

Predictive Factors for Severity Assessment

The TG13 guidelines identify five predictive factors for poor prognosis that help determine Grade II classification:

• Hyperbilirubinemia 3
• High fever 3
• Leukocytosis 3
• Elderly patient 3
• Hypoalbuminemia 3

Grade II can be diagnosed if two of these five factors are present 3.

Diagnostic Criteria

The diagnosis of acute cholangitis is based on:

• Clinical manifestations: Charcot's triad (fever/chills, abdominal pain, jaundice) 2, 4
• Laboratory data: Evidence of inflammation and cholestasis 2, 4
• Imaging findings: Evidence of biliary obstruction 2, 4

Management Based on Classification

Treatment approach is determined by severity classification:

• All grades: Require appropriate antimicrobial therapy initiated empirically (within 1 hour for septic patients, within 6 hours for less severe cases) 1

• Grade III: Urgent biliary decompression with focus on decompression rather than definitive treatment 1

• Grade II: Early biliary decompression (preferably within 24 hours) 1

• Grade I: Initial medical management with antibiotics, with elective drainage procedures if needed 1

Preferred Drainage Methods

• ERCP with stent placement is the first-line procedure for biliary drainage, demonstrating better outcomes compared to percutaneous transhepatic biliary drainage or surgical approaches 1

• Percutaneous approaches are reserved for cases where endoscopic approaches fail or are not feasible 1

• Open surgical drainage is now extremely rare due to widespread availability of endoscopic and percutaneous techniques 1

Clinical Pitfalls and Caveats

• Severity assessment should be performed at diagnosis and reassessed frequently as patients may progress from one grade to another 1, 3

• Delaying biliary drainage in Grade II patients beyond 24 hours is associated with increased mortality 1

• Obesity has been identified as a risk factor for the development of acute cholangitis and may affect severity assessment 1

• Hospital stays are shorter for patients treated with biliary drainage within 24 hours of admission, regardless of severity 1