What is the initial approach to managing a patient suspected of having acute cholangitis or cholecystitis according to the Tokyo Guidelines 2018?

Tokyo Guidelines 2018: Initial Management of Acute Cholangitis and Cholecystitis

Immediate Assessment and Stabilization

Begin with vital sign measurement to determine urgency—if unstable, initiate respiratory and circulatory support immediately before completing diagnostic workup. 1

• Start initial medical treatment without waiting for definitive diagnosis in urgent cases 1
• Measure vital signs first to assess hemodynamic stability 1
• Provide appropriate organ support for severe cases before proceeding with drainage 2, 1

Diagnostic Approach

Clinical Diagnosis Criteria

For acute cholangitis, diagnosis requires clinical signs (fever, chills, jaundice, right upper quadrant pain), laboratory findings (inflammation markers and biliary stasis indicators), and imaging evidence of biliary dilatation or obstruction etiology. 3

• Perform abdominal examination and obtain medical history 1
• Order blood tests and urinalysis 1
• Apply TG18 diagnostic criteria which demonstrate 86% sensitivity and 63% specificity, with 81% overall accuracy—significantly better than clinical assessment alone (71% accuracy, 0% specificity) 4

Imaging Strategy

Obtain abdominal ultrasound as the initial imaging modality for suspected acute cholecystitis or cholangitis. 3

• Ultrasound is the investigation of choice despite lower sensitivity due to wide availability 3, 5
• If initial ultrasound is inconclusive, proceed with CT with IV contrast, MRI/MRCP, or HIDA scan 3
• For cholecystitis, look for pericholecystic fluid, distended gallbladder, edematous wall, gallstones impacted in cystic duct, and positive sonographic Murphy's sign 3

Severity Grading and Treatment Algorithm

Grade I (Mild) Acute Cholangitis

Initial medical treatment with antibiotics is sufficient for most mild cases; biliary drainage is only needed for non-responders. 2, 1

• Administer broad-spectrum antibiotics covering Gram-negative enteric bacteria within 4-6 hours 6
• Observe with medical treatment initially 6
• Consider biliary drainage only if patient fails to respond to initial treatment 2, 1
• If drainage is performed, endoscopic sphincterotomy for choledocholithiasis may be done simultaneously 2

Grade II (Moderate) Acute Cholangitis

Perform early biliary drainage within 24 hours along with antibiotic administration—this significantly reduces 30-day mortality and shortens hospital stays. 6, 2, 1

• Initiate broad-spectrum antibiotics within 4-6 hours of diagnosis 6
• Perform early endoscopic or percutaneous transhepatic biliary drainage 2, 1
• Treat underlying etiology after general condition improves 2, 1
• Early drainage within 24 hours is critical for reducing mortality compared to delayed drainage 6

Grade III (Severe) Acute Cholangitis

Provide urgent biliary drainage after hemodynamic stabilization—administer antibiotics within 1 hour if septic shock is present. 5, 6, 2, 1

• Start broad-spectrum antibiotics within 1 hour for septic shock cases 5, 6
• Provide appropriate respiratory and circulatory management first 2, 1
• Perform urgent endoscopic or percutaneous transhepatic biliary drainage as soon as hemodynamically stable 2, 1
• Focus on decompression rather than definitive treatment of obstruction initially 6

Biliary Drainage Modality Selection

ERCP with stent placement is the procedure of choice, demonstrating superior safety and effectiveness compared to percutaneous or surgical approaches. 6

• ERCP has the lowest risk of adverse events among all drainage methods, with pancreatitis occurring in approximately 3.5% of cases 6
• Use percutaneous transhepatic biliary drainage (PTBD) when ERCP fails or is not feasible, or in patients with altered anatomy 5, 6
• Avoid open surgical drainage in severe cholangitis due to availability of less invasive techniques 5, 6
• EUS-guided drainage serves as an alternative method 5

Antibiotic Management

Antibiotic duration can be limited to 3 days with successful biliary drainage. 5, 6

• Target Gram-negative enteric bacteria with broad-spectrum coverage 5, 6
• For non-critically ill immunocompetent patients with adequate source control: Amoxicillin/clavulanate 2g/0.2g q8h 3
• For critically ill or immunocompromised patients: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g continuous infusion 3
• For septic shock: Meropenem 1g q6h by extended infusion, or doripenem 500mg q8h by extended infusion, or imipenem/cilastatin 500mg q6h by extended infusion 3

Acute Cholecystitis Management

Grade I (Mild) Acute Cholecystitis

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is first-line treatment, requiring only single-shot prophylaxis with no postoperative antibiotics. 3, 2

Grade II (Moderate) Acute Cholecystitis

Delayed/elective laparoscopic cholecystectomy after initial medical treatment is first-line; consider gallbladder drainage for non-responders. 3, 2

• Antibiotic therapy for no more than 7 days 3
• Gallbladder drainage indicated if no response to initial medical treatment 2

Grade III (Severe) Acute Cholecystitis

Urgent or early gallbladder drainage is recommended with appropriate organ support, followed by elective cholecystectomy after inflammatory process improves. 2

• Cholecystostomy may be an option for patients with multiple comorbidities unfit for surgery who do not improve after antibiotic therapy 3
• Note that cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 3

Critical Pitfalls to Avoid

• Do not delay antibiotics waiting for imaging—start within 1 hour for septic shock, within 4-6 hours otherwise 5, 6
• Do not perform surgical drainage in severe cholangitis when endoscopic or percutaneous options are available 5, 6
• Do not continue antibiotics beyond 3 days if drainage is successful 5, 6
• Do not rely solely on clinical assessment—TG18 criteria significantly improve diagnostic accuracy and reduce false positives 4