Clinical application and verification of the <scp>TG</scp>13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study

Kiriyama, Seiki; Takada, Tadahiro; Hwang, Tsann‐Long; Akazawa, Kohei; Miura, Fumihiko; Gomi, Harumi; Mori, Rintaro; Endo, Itaru; Itoi, Takao; Yokoe, Masamichi; Chen, Miin‐Fu; Jan, Yi-Yin; Ker, Chen‐Guo; Wang, Hsiu-Po; Wada, Keita; Yamaue, Hiroki; Miyazaki, Masaru; Yamamoto, Masakazu

doi:10.1002/jhbp.458

Cited by 90 publications

(101 citation statements)

References 22 publications

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“…Two observational studies addressed the timing of biliary drainage by severity grade. A multicenter joint study carried out in Japan and Taiwan found that for moderate cholangitis, mortality was significantly lower in 944 patients who underwent drainage within 24 h compared with 1,081 patients who either underwent drainage after longer than 24 h or did not undergo drainage (1.7% vs. 3.4%, P = 0.0172), but that there was no significant difference for mild or severe cholangitis . In the other observational study, which compared 130 patients with mild or moderate cholangitis who underwent drainage within 24 h and 82 who underwent drainage after longer than 24 h, although there was no significant difference in mortality which was zero in both groups, the mean duration of hospitalization was significantly shorter for patients who underwent drainage within 24 h (6.8 days vs. 9.2 days, P < 0.01 (CS) .…”

Section: Flowchart For the Initial Response To Acute Biliary Infectionmentioning

confidence: 98%

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

Miura

Okamoto

Takada

et al. 2018

J Hepato Biliary Pancreat

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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.

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Section: Flowchart For the Initial Response To Acute Biliary Infectionmentioning

confidence: 98%

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

Miura

Okamoto

Takada

et al. 2018

J Hepato Biliary Pancreat

Self Cite

274

229

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“…Although Charcot's triad provides highly specific diagnostic criteria , studies have reported its sensitivity to be on the order of 50 to 70% . More recent multicenter case series studies showed Charcot's triad diagnosis rates to be much lower (26.4% and 21.2% ). Thus, the ability of this method to diagnose AC is severely limited.…”

Section: Diagnostic Criteria For Acute Cholangitismentioning

confidence: 99%

“…The entire literature on TG13 diagnostic criteria for AC consisted of two case series studies , indicating the paucity of studies in this area. Recently a large‐scale multicenter case series study to validate the TG13 diagnostic criteria for AC was conducted at sites in Japan and Taiwan . This study enrolled patients who were clinically diagnosed with AC and admitted for treatment over a 2‐year period between 2011 and 2013, prior to the publication of the TG13 guidelines.…”

Section: Diagnostic Criteria For Acute Cholangitismentioning

confidence: 99%

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Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Kiriyama

Kozaka

Takada

et al. 2018

J Hepato Biliary Pancreat

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445

425

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Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. 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.

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“…AC complicated by sepsis-induced organ dysfunction is classified as severe by the TG18 criteria and these patients require intensive care level support with emergency (within 12 h) biliary drainage. 8 Although TG18 do not provide recommendations for identifying sepsis in AC patients, they do include two SIRS criteria, white blood cell count (WBC) >12 000/mm 3 and WBC <4000/mm 3 , as diagnostic standards for moderate AC. The SIRS and TG18 criteria have not been compared as screening tools for sepsis in patients with AC.…”

Section: Introductionmentioning

confidence: 99%

Screening acute cholangitis patients for sepsis

Beliaev

Zyul'korneeva

Rowbotham

et al. 2019

ANZ Journal of Surgery

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Background Acute cholangitis (AC) complicated by septic shock is associated with 40% mortality. The best screening method for diagnosing sepsis in patients with AC is unknown. In this study, we aimed to compare the discriminative powers of systemic inflammatory response syndrome criteria (SIRS test) and the 2018 Tokyo Guidelines for moderate cholangitis (TG18 test) in screening AC patients for sepsis and to estimate their predictive abilities. Methods This was a retrospective diagnostic accuracy study in which the TG18 and SIRS tests were applied to two groups of patients; 52 patients with 70 hospital admissions had AC with shock index ≥0.7 and 46 patients with 57 hospital admissions had AC with shock index <0.7, uncomplicated choledocholithiasis, obstructive jaundice and biliary stent removal. Results The sensitivity and specificity for the TG18 test in identifying AC patients with sepsis were 69% and 68%, respectively. The SIRS test applied to the same patient cohort yielded 93% sensitivity and 79% specificity. The SIRS test had a larger area under the receiver operating characteristic curve, 86% and 69%, respectively (P = 0.0004). With a sepsis prevalence of 23% in patients with biliary tract infections, the positive predictive value (PPV) for the SIRS test was 57% (95% confidence interval (CI) 44–69%) and the negative predictive value was 97% (95% CI 94–99%). The PPV and negative predictive value for the TG18 criteria were 39% (95% CI 30–50%) and 88% (95% CI 83–92%), respectively. Conclusion The SIRS test had better discriminative power in identifying AC patients with sepsis than the TG18 criteria, but had a low PPV.

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Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study

Cited by 90 publications

References 22 publications

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

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

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Screening acute cholangitis patients for sepsis

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