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Hepatobiliary SurgeryEmergency

Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)

Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18): Acute Cholangitis - Hepatobiliary Referral → Hepatobiliary Assessment → TG18 Severity Grading ...

Pathway Overview

11 steps

Algorithm Steps

11 total

  1. 01Start

    Acute Cholangitis - Hepatobiliary Referral

    Complex/refractory cases or ERCP failure

  2. 02Action

    Hepatobiliary Assessment

    When is HPB consultation needed?

    • INDICATIONS FOR HPB CONSULT:
    • - Failed ERCP (2+ attempts)
    • - Complex biliary anatomy
    • - Surgical etiology (bile duct injury)
    • - Malignant biliary obstruction
    • - Grade III (severe) cholangitis
    • - Recurrent cholangitis
  3. 03Decision

    TG18 Severity Grading

    Determines urgency

    • Grade I: Mild - No organ dysfunction
    • Grade II: Moderate - Risk factors
    • Grade III: Severe - Organ dysfunction
  4. 04Warning

    Grade III (Severe)

    URGENT biliary drainage

    • ANY ONE organ dysfunction:
    • - Hypotension requiring pressors
    • - Altered mental status
    • - PaO2/FiO2 <300
    • - Creatinine >2.0 mg/dL
    • - INR >1.5
    • - Platelets <100,000
    • REQUIRES:
    • - ICU admission
    • - Urgent drainage (<12-24h)
    • - Organ support
  5. 05Action

    Biliary Drainage Hierarchy

    HPB surgeon coordinates approach

    • 1. ERCP (if not failed/contraindicated)
    • - Success rate 90-95%
    • 2. PTC (percutaneous transhepatic)
    • - When ERCP fails
    • - Proximal obstruction
    • - Altered anatomy (Roux-en-Y)
    • 3. EUS-guided drainage (emerging)
    • 4. SURGICAL drainage (last resort)
  6. 06Action

    PTC Drainage

    When ERCP not possible

    • Percutaneous transhepatic cholangiography
    • INDICATIONS:
    • - Failed ERCP
    • - Roux-en-Y anatomy
    • - Proximal obstruction (Klatskin)
    • - Duodenal obstruction
    • TECHNIQUE:
    • - US or fluoro-guided
    • - Right > left approach usually
    • - External drain initially
    • - Can convert to internal later
  7. 07Action

    Definitive Source Management

    After stabilization

    • CHOLEDOCHOLITHIASIS:
    • - CBD clearance (ERCP/surgery)
    • - Cholecystectomy (interval or same admission)
    • MALIGNANT STRICTURE:
    • - Staging workup
    • - Metal stent vs surgery
    • - Oncology consultation
    • BILE DUCT INJURY:
    • - Hepaticojejunostomy (delayed)
    • - Referral to high-volume center
    • BENIGN STRICTURE:
    • - Serial dilation/stenting
    • - Consider surgical bypass
  8. 08Action

    Antibiotic Management

    Empiric coverage

    • EMPIRIC (before cultures):
    • - Pip-Tazo 4.5g IV q6h OR
    • - Ceftriaxone + Metronidazole OR
    • - Meropenem (if MDR risk)
    • ADJUST per culture results
    • DURATION:
    • - 4-7 days after source control
    • - Longer if undrained/bacteremia
  9. 09Action

    Post-Drainage Surveillance

    Monitor for complications

    • Serial LFTs (daily until improving)
    • Repeat imaging if not improving
    • Drain output monitoring
    • Watch for: Recurrent cholangitis, abscess, leak
    • Plan for definitive surgery if needed
  10. 10Outcome

    Outcomes

    Prognosis

    • Grade I: Mortality <1%
    • Grade II: Mortality 5-10%
    • Grade III: Mortality 10-30%
    • Delay in drainage: Increased mortality
    • Surgical drainage: Higher morbidity but effective
  11. 11Warning

    Surgical Biliary Drainage

    When interventional approaches fail

    • INDICATIONS:
    • - Failed ERCP + PTC
    • - Peritonitis requiring laparotomy
    • - Bile duct injury requiring repair
    • - Gallbladder source (cholecystectomy)
    • OPTIONS:
    • - CBD exploration + T-tube
    • - Cholecystostomy (if high-risk)
    • - Choledochojejunostomy (rare acute)
    • HIGH MORBIDITY in acute setting
  12. Path rejoins step 07Shared downstream outcome
  13. Path rejoins step 11Shared downstream outcome
  14. Path rejoins step 05Shared downstream outcome

Guideline Source

Tokyo Guidelines 2018 (TG18) - Surgical Management of Cholangitis

DOI: 10.1002/jhbp.518

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Severity may evolve rapidly
  • ERCP availability varies
  • Surgical drainage reserved for failed endoscopic/percutaneous
  • Elderly/immunocompromised may not mount typical response

Applicable Regions

USEU
Version 1Next review: 2027-01-11

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Frequently Asked Questions

What is the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)?

The Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on Tokyo Guidelines 2018 (TG18) - Surgical Management of Cholangitis.

What guideline is the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18) based on?

This algorithm is based on Tokyo Guidelines 2018 (TG18) - Surgical Management of Cholangitis (DOI: 10.1002/jhbp.518).

What are the limitations of the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)?

Known limitations include: Severity may evolve rapidly; ERCP availability varies; Surgical drainage reserved for failed endoscopic/percutaneous; Elderly/immunocompromised may not mount typical response. Individual patient factors may require deviation from these recommendations.

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