Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Abstract

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

The Comparison of Clinical Outcomes in Elderly (≥75 Years) and Non-Elderly (<75 Years) Patients with Acute Cholangitis Due to Choledocholithiasis

“…The mortality rate in our study was 2.7%, much lower than the 5-10% reported in other studies [15], but comparable to the 1.5% reported in the study by Park et al, which performed early ERCP in most patients (92.7%) [16]. The positive outcome in this study could be attributed to early biliary drainage being performed in most patients with acute cholangitis within 48 h. We treated 91.6% (238 out of 260) of the patients with early ERCP or PTBD.…”

Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios)

“…To the best of our knowledge, this is the first study to present practical ED factors for the clinical outcomes of AC. The existing TG2018 guidelines categorize AC into mild, moderate, and severe and provide algorithms for supportive care, early ERCP biliary drainage, and emergent ERCP within 6 h [6]. In particular, in severe forms of cholangitis, if ERCP fails, endoscopic ultrasound-guided choledochoduodenostomy is performed, and if that fails, PTBD is performed [19].…”

“…The indications for PTBD were as follows: (1) anatomical reasons-the patient's biliary structures were in an unusual position or had been altered by previous surgery, making endoscopic retrograde cholangiopancreatography (ERCP) difficult, and (2) failure of ERCP, the procedure was attempted and did not successfully eliminate the cause. The typical indications for ETI include (1) respiratory failure, (2) loss of consciousness, or (3) airway obstruction [6].…”

“…Moreover, the system predicts the severity and prognosis of AC based on a patient's clinical characteristics and laboratory tests [4,5]. The early use of such a scoring system, especially in the ED, can provide important information for initial diagnosis and treatment planning [6]. These international guidelines grade AC based on 11 parameters after diagnosing AC using components A (systemic inflammation), B (cholestasis), and C (imaging) [4].…”

Updates on Antibiotic Regimens in Acute Cholecystitis

“…It is very often diagnosed in immunosuppressed patients, due to the greater susceptibility of these patients to certain opportunistic infections such as Cytomegalovirus and Cryptosporidium, which can proliferate in the bile [13]. Acute acalculous cholecystitis (AAC) can be distinguished into two forms: primary AAC, associated with a preexisting severe disease, and secondary AAC, which may complicate systemic bacterial, viral, or fungal infections [14,15]. Other risk factors for the development of AAC are total parenteral nutrition, intensive care unit hospitalization, major surgeries, heart attack, stroke, sepsis, severe burns, and extensive trauma [16].…”