Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis

Abstract

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/ cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/ circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Usefulness of newly modified fully covered metallic stent of 12 mm in diameter and anti‐migration feature for periampullary malignant biliary strictures: Comparison with conventional standard metal stent

“…The other procedure‐related adverse events evaluated were cholangitis, cholecystitis, pancreatitis, and hemobilia. Acute cholangitis and cholecystitis were diagnosed according to the 2018 Tokyo Guideline . Acute pancreatitis was defined as typical abdominal pain and an at least threefold elevation in pancreatic enzyme levels 24 h after the procedure.…”

Modified non‐flared fully covered self‐expandable metal stent versus plastic stent for preoperative biliary drainage in patients with resectable malignant biliary obstruction

“…Acute cholangitis and cholecystitis were diagnosed according to the Tokyo Guideline 2018. 7,8 Acute pancreatitis was defined as abdominal pain and ≥ 3-fold elevation in pancreatic enzyme levels 24 h after the procedure. Bleeding was defined as post-procedure hemorrhage that required blood transfusion or intervention.…”

Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity‐matched analysis

“…Cholangitis and cholecystitis as late adverse events were defined according to the current version of the Tokyo guidelines for the management of acute cholangitis and cholecystitis (Japanese Society of Hepato-Biliary-Pancreatic Surgery). 40,41 Propensity score matching…”