What are the diagnostic criteria and treatment guidelines for cholangitis according to the Tokyo Guidelines 2018?

Tokyo Guidelines 2018 Diagnostic Criteria for Acute Cholangitis

The Tokyo Guidelines 2018 (TG18) diagnose acute cholangitis using a combination of clinical signs (fever/chills, abdominal pain, jaundice), laboratory findings (inflammatory markers and biliary stasis indicators), and imaging evidence of biliary dilatation or obstruction. 1

Diagnostic Criteria

Clinical Manifestations (Charcot's Triad)

• Fever and/or chills 2, 1
• Abdominal pain in the right upper quadrant or epigastric region 2, 1
• Jaundice 2, 1

When all three components of Charcot's triad are present, the diagnosis is straightforward. However, when not all components are present, a definite diagnosis requires supporting laboratory and imaging data. 3, 1

Laboratory Findings

• Indicators of inflammation: elevated white blood cell count, C-reactive protein >75 mg/L 2
• Indicators of biliary stasis: elevated alkaline phosphatase (most common biochemical abnormality), elevated bilirubin (>2x upper limit of normal), elevated aminotransferases 2, 4

Imaging Findings

• Biliary dilatation on imaging studies 2, 1
• Evidence of etiology: stricture, stone, or obstructing mass 2, 1

Imaging Algorithm

Initial Imaging

Abdominal ultrasound is the recommended first-line imaging modality for suspected acute cholangitis. 2, 4

Subsequent Imaging (if ultrasound is equivocal/nondiagnostic)

• CT with intravenous contrast is the preferred next step when clinical suspicion persists 2
• MRI/MRCP is reasonable when both ultrasound and CT are inconclusive but acute cholangitis remains suspected 2

The TG18 criteria demonstrated 86% sensitivity, 63% specificity, and 81% overall accuracy in validation studies, significantly improving specificity compared to clinical assessment alone (which had 0% specificity). 5

Severity Grading (TG18)

The TG18 classifies acute cholangitis into three severity grades based on organ dysfunction and response to initial treatment: 3, 1

Grade III (Severe)

Acute cholangitis accompanied by at least one new-onset organ dysfunction, including:

• Cardiovascular dysfunction (hypotension requiring vasopressors)
• Neurological dysfunction (altered mental status)
• Respiratory dysfunction (PaO2/FiO2 ratio <300)
• Renal dysfunction (oliguria, creatinine >2.0 mg/dL)
• Hepatic dysfunction (INR >1.5)
• Hematological dysfunction (platelet count <100,000/μL) 3, 1

Grade II (Moderate)

Acute cholangitis without organ dysfunction that does not respond to initial medical treatment, with persistent or worsening clinical manifestations and/or laboratory abnormalities. 3, 1

Grade I (Mild)

Acute cholangitis that responds to initial medical treatment with improvement in clinical findings. 3, 1

Treatment Implications by Severity

Grade I (Mild)

• Medical treatment with antibiotics may be sufficient 6, 1
• Elective biliary drainage if needed after clinical improvement 7

Grade II (Moderate)

• Early biliary drainage should be performed within 24-48 hours 7, 6
• Validation studies showed significantly lower 30-day mortality in Grade II patients treated with early biliary drainage compared to those who were not 1

Grade III (Severe)

• Urgent biliary drainage within 24 hours after hemodynamic stabilization 7, 6
• Appropriate organ support including ventilatory and circulatory management 6
• Endoscopic or percutaneous transhepatic biliary drainage after stabilization 6

Antibiotic Duration After Drainage

• 4 additional days of antibiotics after successful biliary decompression for uncomplicated acute cholangitis 7
• Extend to 2 weeks for Enterococcus or Streptococcus infections to prevent endocarditis 2, 7
• 7-10 days for severe sepsis, organ dysfunction, or immunocompromised patients 7

Pediatric Considerations

Although acute cholangitis is uncommon in children, it is reasonable to apply the same diagnostic imaging pathway used in adults when cholangitis is suspected in pediatric patients. 2, 4

Clinical Validation

Large-scale validation studies in Japan and Taiwan confirmed that TG18 criteria have higher diagnostic rates than previous Tokyo Guidelines (TG07), and 30-day mortality correlates significantly with severity grade, with Grade III patients having the highest mortality. 8, 1 The mortality benefit from urgent ERCP according to TG18 guidelines has been demonstrated across all age groups, including elderly patients ≥80 years. 8