What guidelines should residents master for the diagnosis, treatment, and management of patients with cholangitis, cholecystitis, gallbladder (GB) stones, and common bile duct (CBD) stones?

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Last updated: January 9, 2026 • View editorial policy

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Mga Guidelines na Dapat Mastery ng mga Residents para sa Cholangitis, Cholecystitis, at Biliary Stones

Dapat ninyong i-master ang Tokyo Guidelines 2018 (TG18) para sa acute cholangitis at cholecystitis, ang 2017 British Society of Gastroenterology/European Society of Gastrointestinal Endoscopy guidelines para sa common bile duct stones, at ang 2020 World Society of Emergency Surgery guidelines para sa acute calculous cholecystitis—ang mga ito ang core references na magde-define ng inyong diagnostic at therapeutic approach sa biliary emergencies.

Tokyo Guidelines 2018 (TG18) para sa Acute Cholangitis

Diagnostic Criteria at Severity Grading

  • Ang TG18 criteria ay may 86% sensitivity at 63% specificity para sa diagnosis ng acute cholangitis, na significantly mas accurate kaysa sa clinical suspicion lang (81% accuracy vs 71%) 1
  • Ang grading system ay naka-base sa severity: Grade I (mild), Grade II (moderate), Grade III (severe) 2
  • Ang TG18 ay nag-improve ng diagnostic specificity at nag-reduce ng false positive rates, preventing unnecessary ERCPs at associated complications 1

Treatment Algorithm Based on Severity

  • Grade I (Mild): Medical treatment lang ang sufficient—antibiotics at supportive care 2
  • Grade II (Moderate): Early biliary drainage dapat i-perform within 72 hours ng presentation 3, 2
  • Grade III (Severe): Kailangan ng urgent organ support (ventilatory/circulatory management), then urgent endoscopic or percutaneous transhepatic biliary drainage after hemodynamic stabilization 2

Pitfall na Iwasan

  • Huwag mag-rely sa clinical suspicion lang—ang TG18 criteria ay may significantly better specificity (63% vs 0%) compared sa fellow assessment 1
  • Patients na may septic shock o hindi responsive sa antibiotics ay kailangan ng urgent biliary decompression 3

2017 BSG/ESGE Guidelines para sa Common Bile Duct Stones

Risk Stratification para sa Choledocholithiasis

  • Gamitin ang modified ASGE risk stratification 4:
    • High risk: Evidence ng CBD stone sa ultrasound O ascending cholangitis 4
    • Intermediate risk: CBD diameter >6mm with bilirubin 1.8-4 mg/dL, O bilirubin >4 mg/dL alone, O abnormal LFTs, O age >55 years, O gallstone pancreatitis 4
    • Low risk: Walang predictors 4

Management Based on Risk Level

  • High-risk patients: Preoperative ERCP with sphincterotomy and stone extraction ang first-line treatment 4, 3
  • Intermediate-risk patients: Kailangan ng second-level imaging (MRCP or EUS preoperatively, OR laparoscopic ultrasound/IOC intraoperatively) bago mag-decide ng ERCP 4
    • Ang MRCP at EUS ay may 93-95% sensitivity at 96-97% specificity, reducing unnecessary ERCPs by 30-75% 4
  • Low-risk patients: Proceed directly to laparoscopic cholecystectomy 4

Laparoscopic Bile Duct Exploration (LBDE)

  • Ang LBDE (transcystic or transductal approach) ay appropriate technique para sa CBD stone removal during laparoscopic cholecystectomy 4
  • May near 100% duct clearance rates kapag may available na intraductal piezoelectric or laser lithotripsy 4
  • Ang primary duct closure ay associated with shorter operative time at faster return to work (around 8 days earlier) 4

Cholecystectomy Recommendations

  • Cholecystectomy is recommended for ALL patients with CBD stones and gallbladder stones unless may specific contraindications 4, 5
  • Ang mortality ay significantly higher sa wait-and-see approach (14.1% vs 7.9%, RR 1.78) over 17 months to 5 years follow-up 4
  • Recurrent pain, jaundice, at cholangitis ay significantly more common kapag hindi nag-undergo ng cholecystectomy 4

Special Situations

  • Patients with empty gallbladder: May lower risk ng recurrent CBD stones (5.9-11.3% vs 15-23.7% sa may gallbladder stones), pwedeng i-discuss ang wait-and-see approach 4
  • Prohibitive surgical risk patients: Biliary sphincterotomy with endoscopic duct clearance alone ay acceptable alternative 4
  • Biliary stenting as definitive treatment: Dapat restricted lang sa patients with limited life expectancy or prohibitive surgical risk 4

2020 World Society of Emergency Surgery Guidelines para sa Acute Calculous Cholecystitis

CBD Stone Risk Assessment sa ACC Patients

  • Gamitin ang modified ASGE classification para sa risk stratification 4:
    • Very strong predictors: CBD stone sa ultrasound, ascending cholangitis 4
    • Strong predictors: CBD >6mm (with gallbladder in situ), total bilirubin >1.8 mg/dL 4
    • Moderate predictors: Abnormal LFTs other than bilirubin, age >55 years, clinical gallstone pancreatitis 4

Management Algorithm

  • High-risk patients (any very strong predictor): Preoperative ERCP, IOC, or LUS depending on local expertise 4
  • Moderate-risk patients: MRCP, EUS, IOC, or LUS bago mag-decide ng ERCP para avoid unnecessary invasive procedures 4
  • Ang implementation ng second-level imaging ay nag-reduce ng ERCP by 30-75% sa non-selected patients 4

Critical Pitfall

  • Huwag mag-ERCP agad sa lahat ng patients with elevated bilirubin—up to 49% ng high-risk patients ay walang CBD stones, kaya ang unnecessary ERCP ay may potential complications 4
  • Ang CBD diameter >6mm ay strong predictor ng choledocholithiasis (aOR 2.16-2.78) 6

Atlanta Guidelines para sa Acute Pancreatitis (Gallstone Pancreatitis Context)

Timing ng Interventions

  • Gallstone pancreatitis with cholangitis or persistent biliary obstruction: ERCP with sphincterotomy and stone extraction within 72 hours ng presentation 5
  • Mild gallstone pancreatitis: Laparoscopic cholecystectomy within 2 weeks, preferably during same hospitalization 5
  • Ang serum total bilirubin sa hospital day 2 ay best predictor ng persistent CBD stones (>1.35 mg/dL may 90.5% sensitivity at 63% specificity) 7

Important Note

  • Ang cholangitis ay uncommon sa gallstone pancreatitis (only 3%), kaya urgent ERCP ay dapat restricted sa patients with documented cholangitis 7

Key Takeaways para sa Practice

Diagnostic Approach

  • Always use TG18 criteria para sa cholangitis diagnosis—mas accurate kaysa clinical judgment alone 1
  • Risk stratify CBD stones systematically using modified ASGE criteria 4, 6
  • Second-level imaging (MRCP/EUS) para sa intermediate-risk patients bago mag-ERCP 4

Therapeutic Approach

  • ERCP with sphincterotomy and stone extraction ang gold standard para sa CBD stones 4, 5, 3
  • Cholecystectomy is mandatory para sa patients with CBD stones and gallbladder stones para prevent mortality at recurrent biliary events 4, 5
  • LBDE ay viable single-stage option kapag may expertise at equipment 4

Common Pitfalls na Iwasan

  • Huwag mag-rely sa clinical suspicion alone—gumamit ng validated criteria 1
  • Huwag mag-ERCP sa lahat ng patients with elevated bilirubin—risk stratify muna 4
  • Huwag mag-leave ng gallbladder in situ after CBD stone clearance—may significantly higher mortality 4
  • Huwag mag-delay ng biliary drainage sa moderate-to-severe cholangitis—within 72 hours ang target 3, 2

References

3
Guideline

Management of Dilated Common Bile Duct Post-Cholecystectomy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Guideline

Manejo de la Colelitiasis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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