What are the recommendations of the Tokyo Guidelines 2018 for managing acute cholangitis and cholecystitis?

Tokyo Guidelines 2018 for Managing Acute Cholangitis and Cholecystitis

The Tokyo Guidelines 2018 (TG18) provide a comprehensive management strategy for acute cholangitis and cholecystitis based on severity assessment, with early biliary drainage recommended for moderate to severe cholangitis and laparoscopic cholecystectomy as the first-line treatment for mild to moderate cholecystitis.

Acute Cholangitis Management

Severity Assessment

• TG18 classifies acute cholangitis into three grades 1:
  • Grade I (mild): No organ dysfunction
  • Grade II (moderate): Risk of increased severity without early biliary drainage
  • Grade III (severe): Presence of organ dysfunction

Treatment Recommendations by Severity

• Grade I (Mild) Cholangitis:

  • Initial medical treatment with antimicrobial agents is sufficient for most cases 2
  • For non-responders to initial medical treatment, biliary drainage should be considered 2
  • Treatment for underlying etiology (e.g., endoscopic sphincterotomy for choledocholithiasis) might be performed simultaneously with biliary drainage if possible 2

• Grade II (Moderate) Cholangitis:

  • Early biliary drainage along with antibiotic administration is recommended 2
  • Treatment for underlying etiology should be performed after the patient's condition improves 2

• Grade III (Severe) Cholangitis:

  • Appropriate organ support is required 2
  • After hemodynamic stabilization, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed 2
  • Treatment for underlying etiology should follow after patient stabilization 2

Antibiotic Therapy

• Empiric broad-spectrum antibiotics should be started promptly 1:
  • For septic shock: administer within 1 hour
  • Otherwise: administer within 4 hours and before drainage procedures
• Recommended antibiotics for biliary infections include piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam 1
• In cases of shock, add amikacin; for fragility or delayed diagnosis, add fluconazole 1
• Duration of antibiotic therapy 1:
  • Additional 4 days after successful biliary drainage
  • 2 weeks if Enterococcus or Streptococcus is present (to prevent endocarditis)
  • 5-7 days for biloma and generalized peritonitis

Biliary Drainage Options

• Endoscopic retrograde cholangiography (ERC) is the preferred method 1
• Alternative options include percutaneous transhepatic cholangiography (PTC), EUS-guided drainage, or surgical drainage 1
• Endoscopic options include biliary stent or nasobiliary drain placement 1
• Urgent ERCP (within 24 hours) has demonstrated mortality benefits across all age groups 3

Acute Cholecystitis Management

Severity Assessment

• TG18 classifies acute cholecystitis into three grades 4:
  • Grade I (mild)
  • Grade II (moderate)
  • Grade III (severe)

Treatment Recommendations by Severity

• Grade I (Mild) Cholecystitis:

  • Early laparoscopic cholecystectomy (Lap-C) is recommended for patients with Charlson comorbidity index (CCI) ≤5 and ASA-PS ≤2 4

• Grade II (Moderate) Cholecystitis:

  • For patients with CCI ≤5 and ASA-PS ≤2: early Lap-C performed by experienced surgeons 4
  • For others: medical treatment and/or gallbladder drainage followed by delayed Lap-C 4

• Grade III (Severe) Cholecystitis:

  • Appropriate organ support plus initial medical treatment 2
  • Urgent or early gallbladder drainage is recommended 2
  • TG18 update: Lap-C may be indicated for selected Grade III patients with favorable organ system failure and negative predictive factors, who meet criteria of CCI ≤3 and ASA-PS ≤2, when performed at advanced centers by experienced surgeons 4
  • Elective cholecystectomy can be performed after improvement of acute inflammation 2

Diagnostic Approach

Acute Cholangitis

• TG18 diagnostic criteria have demonstrated improved specificity (63%) and accuracy (81%) compared to clinical assessment alone 5
• Diagnostic workup includes:
  • Laboratory tests: liver function tests (bilirubin, AST, ALT, ALP, GGT) 1
  • For critically ill patients: CRP, PCT, and lactate levels help evaluate severity 1
  • Imaging: abdominal triphasic CT as first-line, complemented by CE-MRCP for exact visualization of biliary duct injury 1
  • EUS and MRCP have high sensitivity (93% and 85%) and specificity (96% and 93%) for CBD stone detection 1

Acute Cholecystitis

• Prompt investigation for patients with alarm symptoms (fever, abdominal pain, distention, jaundice, nausea, vomiting) 1
• Abdominal triphasic CT is suggested as first-line diagnostic imaging 1

Clinical Pitfalls and Caveats

• Failure to initiate early antibiotic therapy in suspected cholangitis can lead to increased mortality 1
• Delay in biliary drainage for moderate to severe cholangitis worsens outcomes 2
• Bile cultures should be obtained during drainage procedures to guide antibiotic therapy 1
• The presence of residual stones or ongoing biliary obstruction requires extended antimicrobial treatment 1
• For elderly patients (≥80 years), be aware of higher risk of post-sphincterotomy bleeding, though urgent ERCP remains beneficial regardless of age 3
• Recognize that some Grade III acute cholecystitis patients can safely undergo laparoscopic cholecystectomy when strict criteria are met and the procedure is performed by experienced surgeons at advanced centers 4