TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)

Abstract

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016)

“…Diagnostic imaging using ultrasound is recommended in cases of acute suppurative cholangitis, and reaching a definitive diagnosis via CT or magnetic resonance cholangiopancreatography (MRCP) is important when local complications such as perforation or abscess formation are suspected 37. In cases of sepsis caused by urinary tract infection (caused by a kidney stone or indwelling catheter) or infection of the male genitalia, the source of infection can be identified through abdominal ultrasonography or abdominal CT examination 38.…”

Primary Tumor Maximum Standardized Uptake Value Measured on18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Is a Prognostic Value for Survival in Bile Duct and Gallbladder Cancer

“…20 The institutional review board approved this retrospective study and waived patient consent for this specific study (KBC13065).…”

Re: Acute cholangitis: current concepts

“…1,2 The sensitivity of criterion was inadequate for clinical use and the revision had resulted in improved sensitivities from 82.6 to 91.8%, only reducing specificity from 79.8 to 77.7%. The current diagnostic criteria from Tokyo Guidelines of 2013 now have three diagnostic criteria, and a 'suspected diagnosis' section to further improve sensitivity ( Table 1).…”

“…2 Lan Cheong Wah et al suggested that a penicillin/β-lactamase inhibitor such as piperacillin/tazobactam can be used as the initial antibiotic therapy. Current Australian therapeutic guidelines suggesting ampicillin and gentamicin as first line choice.…”

“…Current Australian therapeutic guidelines suggesting ampicillin and gentamicin as first line choice. 2,3 The guideline choice provides optimal coverage of the most common pathogenic organisms as quoted within their paper. We hope that consideration of these concerns will aid in providing a more current concept on acute cholangitis.…”