New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines

Abstract

BackgroundThe Tokyo Guidelines for the management of acute cholangitis and cholecystitis were published in 2007 (TG07) and have been widely cited in the world literature. Because of new information that has been published since 2007, we organized the Tokyo Guidelines Revision Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines (TG13).Methods/materials We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was suspected. The cases were collected from multiple tertiary care centers in Japan. The ‘gold standard’ for acute cholangitis in this study was that one of the three following conditions was present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or (3) remission was achieved by antibacterial therapy alone, in patients in whom the only site of infection was the biliary tree. Comparisons were made for the validity of each diagnostic criterion among TG13, TG07 and Charcot’s triad.ResultsThe major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from 82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of Charcot’s triad was only 26.4 % but the specificity was 95.6 %. However, the false positive rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading, Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors which were derived from evidence presented recently in the literature. The factors chosen allow severity assessment to be performed soon after diagnosis of acute cholangitis.ConclusionTG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.

Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality

“…Findings detectable by abdominal US include bile duct dilatation and evidence of its etiology, such as stricture, stones or stent (6). In the present study, in the absence of these findings, acute cholangitis was not diagnosed by abdominal US, but was based on a combination of symptoms including systemic inflammation and cholestasis (6). Acute cholecystitis was diagnosed by a combination of local and systemic signs of inflammation (7).…”

“…Acute cholangitis is defined as inflammation due to the obstruction of a bile duct (6). Findings detectable by abdominal US include bile duct dilatation and evidence of its etiology, such as stricture, stones or stent (6). In the present study, in the absence of these findings, acute cholangitis was not diagnosed by abdominal US, but was based on a combination of symptoms including systemic inflammation and cholestasis (6).…”

“…Acute cholangitis is defined as inflammation due to the obstruction of a bile duct (6). Findings detectable by abdominal US include bile duct dilatation and evidence of its etiology, such as stricture, stones or stent (6).…”

“…In addition, abdominal US is also useful for the diagnosis of solid organ conditions, including acute cholangitis, acute cholecystitis and acute pancreatitis (6)(7)(8). Abdominal US is also useful in the diagnosis of bowel disease based on pathological findings (9,10).…”

Comparison of acute cholangitis with or without common bile duct dilatation

“…Acute cholangitis is currently diagnosed based on evidence of bile duct obstruction and inflammation (9). Evidence of inflammation includes the presence of fever and elevations in white blood cell (WBC) count and C-reactive protein (CRP) levels, while bile duct obstruction is identified by elevated levels of liver enzymes, including total bilirubin (T-Bil), alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (γ-GTP).…”