What is the recommended management for acute cholangitis according to the Tokyo Guidelines 2018?

Tokyo Guidelines 2018 for Acute Cholangitis Management

The Tokyo Guidelines 2018 recommend a severity-based approach where mild (Grade I) cholangitis is managed with antibiotics alone, moderate (Grade II) requires early biliary drainage within 24 hours, and severe (Grade III) demands urgent biliary drainage as soon as possible after hemodynamic stabilization, with all patients receiving prompt broad-spectrum antibiotics. 1, 2, 3

Diagnosis and Severity Classification

The diagnostic criteria have been refined from the 2007 version to improve sensitivity to 91.8% while maintaining specificity. 4 Acute cholangitis is diagnosed when:

• Systemic inflammation is present (fever/chills and/or elevated inflammatory markers like CRP, WBC) 5, 4
• Cholestasis is documented (jaundice, elevated bilirubin, and/or elevated liver enzymes) 5, 4
• Biliary imaging demonstrates ductal dilation or evidence of obstruction 5, 4

Important caveat: Abdominal pain was removed from the diagnostic criteria in the revised guidelines, as its absence does not exclude cholangitis—this change reduced false positives in acute cholecystitis cases from 15.5% to 5.9%. 4

Severity Grading

Grade III (Severe): Presence of any organ dysfunction including cardiovascular (hypotension requiring vasopressors), neurological (altered mental status), respiratory (PaO2/FiO2 <300), renal (oliguria or creatinine >2.0 mg/dL), hepatic (INR >1.5), or hematological dysfunction (platelet count <100,000/mm³) 5, 4

Grade II (Moderate): No organ dysfunction but presence of at least two of the following: WBC >12,000 or <4,000/mm³, fever ≥39°C, age ≥75 years, hyperbilirubinemia (total bilirubin ≥5 mg/dL), or hypoalbuminemia 4

Grade I (Mild): Does not meet criteria for Grade II or III 5, 4

Antibiotic Management

Timing is critical: Administer broad-spectrum antibiotics within 1 hour for patients with septic shock, and within 4 hours for all other suspected cases, ideally before drainage procedures. 6, 2

Recommended regimens: Piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam (with amikacin added in shock states). 6, 1 Consider adding fluconazole in fragile patients or delayed diagnosis cases. 6

Duration: Continue antibiotics for 4 days after successful biliary drainage. 6, 1 However, extend treatment to 2 weeks if Enterococcus or Streptococcus is isolated to prevent infectious endocarditis. 6, 1 If residual stones or ongoing obstruction persist, continue antibiotics until anatomical resolution is achieved. 6, 2

Bile cultures: Obtain bile samples at the start of any drainage procedure for microbial testing, as bile cultures are positive in 59-93% of cases. 6, 2 Blood cultures (positive in only 21-71% of cases) remain controversial and typically do not alter management. 6

Biliary Drainage Strategy

Grade I (Mild)

Initial medical treatment with antibiotics is usually sufficient, and most patients do not require biliary drainage. 3, 7 However, if the patient fails to respond to initial treatment within 24-48 hours, proceed with biliary drainage. 3

Grade II (Moderate)

Early biliary drainage should be performed, preferably within 24 hours of diagnosis. 2, 3 Endoscopic retrograde cholangiography (ERC) is the preferred first-line method. 1, 2

Endoscopic options include:

• Biliary stent placement (provides better patient comfort) 6
• Nasobiliary drain (allows repeated bile aspiration for cultures and flushing) 6
• Endoscopic sphincterotomy with stone extraction (successful in >90% of cases with <1% mortality) 6

Grade III (Severe)

Provide immediate respiratory and circulatory support with organ-specific management. 3, 7 Once hemodynamic stabilization is achieved, perform urgent biliary drainage as soon as possible. 2, 3, 7

Drainage hierarchy:

1. ERC remains first-line even in severe cases after stabilization 2
2. Percutaneous transhepatic biliary drainage (PTBD) if ERC fails or is not feasible 2
3. Surgical drainage only when endoscopic and percutaneous approaches are unsuccessful or contraindicated 2

Definitive Treatment of Underlying Etiology

After the patient's general condition improves following drainage and antibiotics, address the underlying cause. 3, 7

For choledocholithiasis:

• Endoscopic sphincterotomy with stone extraction can be performed during or after initial drainage 6, 3
• Laparoscopic common bile duct exploration (LCBDE) has comparable stone clearance rates to ERC (91.7% vs 88.1%) and offers shorter hospital stays with lower recurrence rates (2.06% vs 9.47%) 1

Critical surgical timing caveat: Early LCBDE is appropriate only for mild-moderate cholangitis. Never attempt early LCBDE in severe (Grade III) cholangitis, especially in patients >80 years old, due to unacceptably high mortality risk. 1 Additionally, performing cholecystectomy after ERCP is technically more difficult due to severe adhesions (33.4% of cases) and inflammation around Calot's triangle. 1

Common Pitfalls to Avoid

• Delaying antibiotics in severe cases: This directly increases mortality—administer within 1 hour for septic shock 6, 2
• Inadequate drainage: Failure to achieve complete biliary decompression is associated with poor outcomes and requires extended antibiotic therapy 6, 2
• Premature surgical intervention: Attempting LCBDE in severe cholangitis or elderly patients carries prohibitive mortality risk 1
• Overlooking fungal infection: Consider fungal coverage if patients fail to respond to standard antibiotic therapy 2
• Underestimating ICU needs: Severe cholangitis requires intensive care with organ support before drainage 2, 3