Tokyo Guidelines for Acute Cholangitis and Cholecystitis
Overview
The Tokyo Guidelines (TG13, updated from TG07) provide standardized diagnostic criteria, severity grading systems, and treatment algorithms for acute cholangitis and cholecystitis that prioritize early recognition, appropriate antibiotic therapy, and timely biliary drainage to reduce mortality and morbidity. 1, 2
Diagnostic Criteria
Acute Cholangitis
The diagnosis requires clinical manifestations plus supporting evidence 3:
Clinical manifestations (at least one required):
- Fever and/or chills
- Jaundice
- Abdominal pain (right upper quadrant or epigastric)
Note: Charcot's triad (all three above) has only 26.4% sensitivity, making it inadequate as a sole diagnostic criterion 3
Supporting evidence needed when full triad absent:
- Laboratory data showing inflammation (elevated WBC, CRP)
- Imaging demonstrating biliary obstruction or dilatation 4, 3
TG13 improvements over TG07: Sensitivity increased from 82.8% to 91.8%, with false positive rate in acute cholecystitis cases reduced from 15.5% to 5.9% 3
Acute Cholecystitis
Definite diagnosis requires: 5
- Local signs of inflammation (Murphy's sign, right upper quadrant mass/pain/tenderness)
- Systemic signs (fever, elevated inflammatory markers)
- Imaging findings confirming cholecystitis
Imaging modalities: 5
- Ultrasound detects cholelithiasis in ~98% of cases
- Positive predictive value of 92% when stones plus ultrasonographic Murphy's sign present
- Positive predictive value of 95% when stones plus gallbladder wall thickening (≥5mm) present
- Hepatobiliary scintigraphy has 80-90% sensitivity
Severity Assessment
Acute Cholangitis - Three-Tier System 4, 3
Grade III (Severe):
- Presence of at least one organ dysfunction:
- Cardiovascular dysfunction (hypotension requiring dopamine ≥5 μg/kg/min or any norepinephrine)
- Neurological dysfunction (altered consciousness)
- Respiratory dysfunction (PaO2/FiO2 ratio <300)
- Renal dysfunction (oliguria, creatinine >2.0 mg/dL)
- Hepatic dysfunction (PT-INR >1.5)
- Hematological dysfunction (platelet count <100,000/mm³)
Grade II (Moderate):
- No organ dysfunction present
- Associated with any two of these prognostic factors:
- Abnormal WBC count (<4,000 or >12,000/mm³)
- High fever (≥39°C)
- Age ≥75 years
- Hyperbilirubinemia (total bilirubin ≥5 mg/dL)
- Hypoalbuminemia (<standard limit × 0.7)
Grade I (Mild):
- Does not meet criteria for Grade II or III
- Responds to initial medical treatment 4
Acute Cholecystitis 5
Grade III (Severe): Associated with organ dysfunction (same criteria as cholangitis)
Grade II (Moderate): Any one of:
- Elevated WBC count (>18,000/mm³)
- Palpable tender mass in right upper quadrant
- Duration of complaints >72 hours
- Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
Grade I (Mild): Does not meet criteria for Grade II or III
Treatment Algorithm
Antibiotic Therapy
- Septic shock present: Administer antibiotics within 1 hour
- No shock: Administer within 4 hours after diagnostic studies
- Always give before drainage procedures
Empiric antibiotic selection for community-acquired infection: 6
First-line broad-spectrum options:
- Piperacillin/tazobactam
- Carbapenems (imipenem, meropenem, or ertapenem)
- 3rd/4th generation cephalosporins (ceftriaxone, cefepime) plus metronidazole
- Cefazolin, cefamandole, or cefuroxime for prophylaxis 6
Beta-lactam allergy:
- Aminoglycoside (gentamicin) plus metronidazole or clindamycin 6
Healthcare-associated infection considerations:
- Broader coverage may be needed based on local resistance patterns 6
- With successful biliary drainage: 3 days post-drainage is sufficient
- With incomplete drainage or residual stones: Continue until anatomical resolution
- Enterococcus or Streptococcus: 2 weeks to prevent endocarditis 6
- Biloma/peritonitis: 5-7 days 6
Bile cultures: 6
- Obtain at beginning of any drainage procedure (positive in 59-93% of cases)
- Blood cultures have limited utility (positive in 21-71%) and remain controversial
Biliary Drainage
Indications and timing: 1
Grade III (Severe) cholangitis:
- Urgent biliary drainage required (within hours)
- Endoscopic drainage preferred over surgical approach
- Percutaneous transhepatic drainage or EUS-guided drainage as alternatives
- Avoid surgical drainage in severe cholangitis
Grade II (Moderate) cholangitis:
- Early biliary drainage recommended if no response to initial medical treatment within 12-24 hours
Grade I (Mild) cholangitis:
- Approximately 70% respond to medical treatment alone 6
- Drainage if no clinical improvement
Imaging Strategy
- Trans-abdominal ultrasound as first-line (widely available, demonstrates biliary dilatation despite 25-63% sensitivity for CBD stones)
- Bile duct diameter >8mm suggests dilatation
Advanced imaging for CBD stone detection: 6, 1
- MRCP: 85% sensitivity, 93% specificity (weakness in detecting small stones)
- EUS: 93% sensitivity, 96% specificity (superior to MRCP, minimally invasive)
- EUS also superior for detecting malignant causes of cholestasis
CT imaging: 6
- Reserved for unstable patients
- High suspicion of malignancy
- Suspected hepatic abscesses
Critical Pitfalls to Avoid
- Relying solely on Charcot's triad (misses 73.6% of cases)
- Delaying antibiotics beyond recommended timeframes
- Continuing antibiotics unnecessarily long after successful drainage
- Attempting surgical drainage in Grade III cholangitis
- Ignoring obesity as a risk factor for severity progression 6
- Quality of biliary drainage is more important than antibiotic duration
- Early severity assessment guides appropriate level of care (ICU vs ward)
- Incomplete drainage mandates extended antibiotic therapy regardless of clinical improvement