What are the Tokyo guidelines for diagnosing and treating acute cholangitis or cholecystitis?

Tokyo Guidelines for Acute Cholangitis and Cholecystitis

Overview

The Tokyo Guidelines (TG13/TG18) provide a standardized, severity-based framework for diagnosing and managing acute cholangitis and cholecystitis, with diagnostic sensitivity of 91.8% for cholecystitis and 86% for cholangitis, significantly improving upon previous clinical assessment methods. 1, 2, 3

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Diagnostic Criteria for Acute Cholangitis

Clinical Diagnosis (Charcot's Triad)

• Fever and/or chills 4
• Abdominal pain (right upper quadrant or epigastric) 4
• Jaundice 4

When Triad is Incomplete

• Obtain laboratory data showing inflammation (elevated WBC, CRP) 4
• Imaging must demonstrate biliary obstruction or dilatation 5, 4

Imaging Modality Selection

• Initial ultrasound is recommended first-line despite 25-63% sensitivity for CBD stones, due to wide availability and high accuracy for detecting biliary dilatation (normal ≤8mm) 6, 1
• MRCP achieves 85-93% sensitivity and 93% specificity for CBD stone detection 6, 1
• EUS demonstrates superior performance with 93-96% sensitivity and 96% specificity, and is at least equal to ERCP for stone detection 6, 1
• CT is reserved for unstable patients with suspected malignancy or hepatic abscesses 6

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Diagnostic Criteria for Acute Cholecystitis

TG13 Improved Performance

• Diagnostic sensitivity increased from 82.8% to 91.2% 5, 2
• Specificity improved to 96.9% 2
• False positive rate decreased from 15.5% to 5.9% 5, 2

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Severity Assessment (Three-Tier Grading System)

Grade I (Mild)

• Responds to initial medical treatment 4
• Clinical manifestations and laboratory data improve with antibiotics alone 4
• Management: Initial observation with medical treatment; elective drainage after clinical improvement 5

Grade II (Moderate)

• No organ dysfunction present 4
• Does not respond to initial medical treatment 4
• Clinical manifestations and/or laboratory data fail to improve 4
• Management: Early biliary drainage within 24 hours significantly reduces 30-day mortality and shortens hospital stays 5

Grade III (Severe)

• Presence of at least one new-onset organ dysfunction 4
• Patients require ICU admission 6
• Management: Urgent biliary drainage after hemodynamic stabilization, focusing on decompression rather than definitive stone extraction 5

Additional Risk Factors

• Obesity has been identified as an independent risk factor for severity progression 6, 1

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Medical Management

Antibiotic Timing (Critical for Survival)

• Septic shock: Administer broad-spectrum antibiotics within 1 hour of diagnosis 6, 1, 5
• Non-septic cases: Administer within 4-6 hours 6, 5
• Antibiotics must be given before any drainage procedures 6

Antibiotic Coverage

• Target Gram-negative enteric bacteria and enterococci (the predominant gastrointestinal microbiota pathogens) 6, 5
• Biliary-secreted antibiotics theoretically provide superior efficacy 6

Antibiotic Duration

• With successful biliary drainage: 3 days of treatment is sufficient 6, 1, 5
• With residual stones or ongoing obstruction: Extend antimicrobial treatment until anatomical resolution 6

Bile and Blood Cultures

• Bile cultures: 59-93% positive rate; obtain samples at the beginning of any drainage procedure 6
• Blood cultures: 21-71% positive rate; routine use remains controversial as results rarely affect management 6

Supportive Care

• Intravenous fluid resuscitation 5
• Correction of coagulopathies 5

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Biliary Drainage Strategy

Drainage Timing by Severity Grade

• Grade I: Elective drainage after clinical improvement with medical management 5
• Grade II: Early drainage within 24 hours 5
• Grade III: Urgent drainage after hemodynamic stabilization 5

Drainage Modality Selection

First-Line: ERCP with Stent Placement

• Procedure of choice with superior safety and effectiveness compared to all other approaches 5
• Success rate >90% for sphincterotomy and stone extraction 6
• Adverse event rate ~5%, mortality <1% 6
• ERCP-related pancreatitis occurs in approximately 3.5% of cases 5

Stent vs. Nasobiliary Drain

• Equal effectiveness for drainage 6
• Stent advantages: Improved patient comfort 6
• Nasobiliary drain advantages: Allows repeated bile aspiration for microbiology, flushing, and cholangiographic evaluation 6

Second-Line: Percutaneous Transhepatic Biliary Drainage (PTBD)

• Indicated when ERCP fails or is not feasible 5
• Alternative for patients with altered anatomy 5
• Higher complication rates than standard ERCP 6

Third-Line: EUS-Guided Biliary Drainage

• Viable alternative after failed ERCP access 6, 1
• Requires further standardization and clinical trial validation 6

Surgical Drainage

• Should be avoided in severe cholangitis due to widespread availability of less invasive techniques 5
• Now extremely rare for acute cholangitis management 5

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Common Pitfalls and Caveats

Diagnostic Pitfalls

• Do not rely solely on Charcot's triad; incomplete presentations are common and require laboratory/imaging confirmation 4
• Normal bile duct diameter does not exclude cholangitis; evidence of obstruction etiology is required 5

Treatment Pitfalls

• Do not delay antibiotics for diagnostic studies in septic patients; timing is critical for survival 6, 5
• Do not extend antibiotics unnecessarily if drainage is successful; 3 days is sufficient 6, 1, 5
• Do not attempt definitive stone extraction in Grade III patients during initial drainage; focus on decompression only 5
• Minimize biliary tree manipulation in severe cases to reduce complications 5

Severity Assessment Pitfalls

• TG18 criteria provide 86% sensitivity but only 63% specificity, meaning some patients without cholangitis may be over-diagnosed 3
• Fellow clinical assessment alone has 0% specificity, leading to unnecessary ERCPs 3
• Always apply TG18 criteria systematically rather than relying on clinical gestalt to improve accuracy from 71% to 81% 3