Suspected Acute Cholangitis
Systemic inflammation + biliary obstruction + cholestasis
All Pathways
GastroenterologyEmergency
Acute Cholangitis Management (Tokyo Guidelines 2018)
Acute Cholangitis Management (Tokyo Guidelines 2018): Suspected Acute Cholangitis → Apply TG18 Diagnostic Criteria → Initial Management → Antibiotic Sel...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Decision Apply TG18 Diagnostic Criteria
Definite diagnosis requires A + B + C/D
- A: Systemic inflammation (fever >38°C, WBC <4 or >10, CRP elevated)
- B: Cholestasis (jaundice, abnormal LFTs - ALP, GGT, AST, ALT)
- C: Imaging (biliary dilation, etiology seen)
- D: Or known biliary disease
03Action Initial Management
Start immediately on diagnosis
- NPO
- IV fluids for resuscitation
- Blood cultures x2
- Broad-spectrum IV antibiotics (cover gram-neg + anaerobes)
- Pain control
04Action Antibiotic Selection
Cover biliary pathogens
- Mild: Ceftriaxone 1-2g IV + Metronidazole 500mg IV
- Moderate-Severe: Piperacillin-tazobactam 4.5g IV q6h
- OR Meropenem 1g IV q8h (severe/MDR risk)
- Duration: 4-7 days after source control
05Decision TG18 Severity Grading
Determines urgency of drainage
06Action Grade I (Mild)
Does not meet Grade II/III criteria
- Responds to initial treatment
- No organ dysfunction
- Early elective drainage (24-48h)
07Decision Biliary Drainage Method
ERCP is first-line
08Action ERCP with Sphincterotomy/Stent
First-line drainage method
- Sphincterotomy + stone extraction if possible
- Biliary stent if unable to clear duct
- ENBD (nasobiliary drain) for severe cases
- Success rate >90%
09Action Post-Drainage Management
After successful drainage
- Continue antibiotics 4-7 days
- Advance diet as tolerated
- Plan definitive treatment
- Cholecystectomy if gallstone etiology
10Outcome Cholangitis Resolved
Plan interval cholecystectomy within 2-4 weeks if gallstone etiology
11Outcome Surgical Drainage
If endoscopic and percutaneous fail - open or laparoscopic CBD exploration
12Action PTC/PTBD
Percutaneous Transhepatic Cholangiography
- If ERCP fails or not available
- Altered anatomy (Roux-en-Y, etc.)
- External or internal-external drain
- Path rejoins step 09Shared downstream outcome
13Action EUS-Guided Drainage
Alternative if ERCP fails
- EUS-guided choledochoduodenostomy
- EUS-guided hepaticogastrostomy
- Requires expertise
- Path rejoins step 09Shared downstream outcome
14Action Grade II (Moderate)
Any 2 of following
- WBC >12,000 or <4,000
- Fever ≥39°C
- Age ≥75
- Bilirubin ≥5 mg/dL
- Albumin <0.7 × lower limit
- Urgent drainage within 24-48h
- Path rejoins step 07Shared downstream outcome
15Warning ⚠️ Grade III (Severe)
Organ dysfunction present
- Cardiovascular: dopamine ≥5μg/kg/min OR any norepinephrine
- Neurological: altered consciousness
- Respiratory: PaO2/FiO2 <300
- Renal: oliguria, Cr >2.0
- Hepatic: INR >1.5
- Hematological: Plt <100,000
- EMERGENCY drainage + ICU
- Path rejoins step 07Shared downstream outcome
Guideline Source
Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholangitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Severity grading requires organ function assessment
- ERCP availability varies by institution
- Antibiotic choice should be adapted to local patterns
- PTC may be needed if ERCP fails
Applicable Regions
USEUAsiaGlobal
US: ASGE guidelines align with TG18
Global: Tokyo Guidelines 2018 are internationally accepted
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the Acute Cholangitis Management (Tokyo Guidelines 2018)?
The Acute Cholangitis Management (Tokyo Guidelines 2018) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholangitis.
What guideline is the Acute Cholangitis Management (Tokyo Guidelines 2018) based on?
This algorithm is based on Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholangitis (DOI: 10.1002/jhbp.518).
What are the limitations of the Acute Cholangitis Management (Tokyo Guidelines 2018)?
Known limitations include: Severity grading requires organ function assessment; ERCP availability varies by institution; Antibiotic choice should be adapted to local patterns; PTC may be needed if ERCP fails. Individual patient factors may require deviation from these recommendations.
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