Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality

Abstract

<b><i>Background:</i></b> Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC. <b><i>Methods:</i></b> This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality. <b><i>Results:</i></b> Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8–82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; <i>p</i> < 0.006). The majority of the patients (<i>n</i> = 178; 67.9%) presented with abdominal pain, pyrexia (<i>n</i> = 156; 59.5%), and vomiting (<i>n</i> = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354–116.015; <i>p</i> = 0.026), systolic blood pressure <100 mm Hg (OR = 10.108; 95% CI 1.094–93.395; <i>p</i> = 0.041), Glasgow coma score <15 (OR = 38.16; 95% CI 1.804–807.191; <i>p</i> = 0.019), and malignancy (OR = 14.135; 95% CI 1.017–196.394; <i>p</i> = 0.049) predicted in-hospital mortality. <b><i>Conclusion:</i></b> TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure <100 mm Hg, Glasgow coma score <15, and malignant etiology predict in-hospital mortality in patients with AC. These predictors could be considered in acute stratification and treatment of patients with AC.

Implications of Type 2 Diabetes Mellitus in Patients with Acute Cholangitis: A Systematic Review of Current Literature

“…The 14 selected manuscripts were published between 2011 and 2022 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. Most of the analyzed data were derived from retrospective cohort studies [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 37 , 38 , 39 , 40 ] with the exception of two investigations, namely one prospective study [ 36 ] and one case series [ 34 ]. The number of subjects who partook in these assessments ranged from 12 to 123,990 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ].…”

“…Most of the analyzed data were derived from retrospective cohort studies [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 37 , 38 , 39 , 40 ] with the exception of two investigations, namely one prospective study [ 36 ] and one case series [ 34 ]. The number of subjects who partook in these assessments ranged from 12 to 123,990 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. Most of the research was carried out in Asia: two studies were conducted in Singapore [ 28 , 36 ], two in China [ 31 , 32 ], one in India [ 37 ], one in South Korea [ 35 ], and one in Israel [ 33 ].…”

“…The number of subjects who partook in these assessments ranged from 12 to 123,990 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. Most of the research was carried out in Asia: two studies were conducted in Singapore [ 28 , 36 ], two in China [ 31 , 32 ], one in India [ 37 ], one in South Korea [ 35 ], and one in Israel [ 33 ]. The remaining studies were conducted in the United States of America, i.e., two studies [ 27 , 38 ], and in Europe, i.e., Denmark [ 40 ], France [ 34 ], or Spain [ 30 ], or were the fruit of international collaboration [ 39 ].…”

Validation of TG07 and TG13/TG18 criteria for acute cholangitis and predictors of in‑hospital mortality in patients over 80 years old

“…Thus, it is likely that mortality risk is not solely determined by age. In a local study including 272 patients with AC, we reported that T2DM ( p = 0.026, OR = 12.5, 95% CI: 0.354-116.015), systolic blood pressure < 100 mmHg ( p = 0.041, OR = 10.1, 95% CI: 1.094-93.395), Glasgow Coma Scale score < 15 ( p = 0.019, OR = 38.2, 95% CI: 1.804-807.191), and malignant disease ( p = 0.049, OR = 14.1, 95% CI: 1.017-196.394) predicted in-hospital mortality [ 37 ]. However, due to the small sample and low mortality in the study population, the confidence intervals are wide, and the results need to be validated.…”

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

“…Among the patients with sepsis complications, 85% will have acute cholecystitis and 15% acute cholangitis. The severity stratification for acute cholecystitis, acute cholangitis, and acute biliary pancreatitis was applied as per our previous reports[ 114 , 141 , 142 ]. Finally, the risk of routine laparoscopic cholecystectomy was assumed as 0.5%, risks of ERCP followed by laparoscopic cholecystectomy at 3%, risks of multiple ERCPs with laparoscopic subtotal cholecystectomy at 15%-25%, and one-third of patients with percutaneous cholecystostomy would not proceed with cholecystectomy (Figure 1 ).…”