What is the Tokyo Guideline?
The Tokyo Guidelines are internationally recognized, evidence-based clinical practice guidelines that provide standardized diagnostic criteria, severity grading systems, and treatment algorithms for the management of acute cholangitis and acute cholecystitis. 1, 2
Development and Evolution
The Tokyo Guidelines were first published in 2007 (TG07) after an International Consensus Meeting held in Tokyo in 2006, bringing together gastroenterologists, surgeons, and critical care specialists to establish the first practical, globally accepted standards for managing acute biliary infections. 2
The guidelines underwent major revision in 2013 (TG13) to address key limitations identified in clinical practice, particularly the low diagnostic sensitivity for acute cholangitis and discrepancies between severity assessment and clinical judgment. 1 The revision process involved 35 committee meetings and three international consensus conferences, with retrospective multi-center analyses validating the updated criteria. 1
The most recent iteration, Tokyo Guidelines 2018 (TG18), further refined the management bundles and incorporated new evidence on diagnostic and therapeutic modalities. 3
Core Components
Diagnostic Criteria for Acute Cholangitis
The Tokyo Guidelines establish that acute cholangitis can be diagnosed based on Charcot's triad: fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice. 4 When the complete triad is absent, definitive diagnosis requires laboratory data and imaging findings demonstrating inflammation and biliary obstruction. 4 TG13 improved diagnostic sensitivity from 82.8% to 91.8% while reducing false positive rates from 15.5% to 5.9%. 5, 1
Severity Grading System
The Tokyo Guidelines classify acute cholangitis into three severity grades that directly determine treatment urgency: 6, 5
- Grade I (Mild): Responds to initial medical treatment with clinical improvement, no organ dysfunction present 4
- Grade II (Moderate): No organ dysfunction but fails to respond to initial medical treatment, requiring early biliary drainage within 24 hours 5, 4
- Grade III (Severe): Accompanied by at least one new-onset organ dysfunction, requiring urgent biliary drainage after hemodynamic stabilization 5, 4
Treatment Algorithms
The Tokyo Guidelines recommend immediate broad-spectrum antibiotics covering Gram-negative enteric bacteria, with administration within 1 hour for septic shock cases and within 4-6 hours for non-shock presentations. 6, 5 Antibiotic duration can be limited to 3 days with successful biliary drainage, though 4 additional days are recommended after source control according to TG18. 7, 6, 5
For biliary drainage, ERCP with stent placement is the procedure of choice, demonstrating superior safety and effectiveness compared to percutaneous or surgical approaches. 5 Percutaneous transhepatic biliary drainage (PTBD) serves as an alternative when endoscopic approaches fail or are not feasible. 5 Open surgical drainage should be avoided in severe cholangitis due to widespread availability of less invasive techniques. 5
Management Bundles
TG13 and TG18 introduced management bundles—specific items and procedures strongly recommended to facilitate guideline implementation and improve patient outcomes. 3 These bundles include the diagnostic process, severity assessment, patient transfer protocols when necessary, and therapeutic approaches at each time point. 3
Clinical Application
The Tokyo Guidelines are referenced extensively in contemporary biliary disease management, with the 2018 version specifically applicable for severity grading and management of cholangitis in complex scenarios including bile duct injuries. 7 The guidelines utilize GRADE systems to provide levels of evidence and grades of recommendations, making them practical for clinical decision-making. 1
Common pitfall: The Tokyo Guidelines should not be viewed as rigid protocols but rather as frameworks that incorporate clinical judgment alongside standardized criteria, particularly when additional factors beyond the core criteria may influence severity assessment. 6