Acute Cholangitis Management (Tokyo Guidelines 2018)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Cholangitis

   Systemic inflammation + biliary obstruction + cholestasis

   1. ◆

      Decision

      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
      1. ●

         Action

         Initial Management

         Start immediately on diagnosis

         • NPO
         • IV fluids for resuscitation
         • Blood cultures x2
         • Broad-spectrum IV antibiotics (cover gram-neg + anaerobes)
         • Pain control
         1. ●

            Action

            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
         2. ◆

            Decision

            TG18 Severity Grading

            Determines urgency of drainage

            1. ●

               Action

               Grade I (Mild)

               Does not meet Grade II/III criteria

               • Responds to initial treatment
               • No organ dysfunction
               • Early elective drainage (24-48h)
               1. ◆

                  Decision

                  Biliary Drainage Method

                  ERCP is first-line

                  1. ●

                     Action

                     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%
                     1. ●

                        Action

                        Post-Drainage Management

                        After successful drainage

                        • Continue antibiotics 4-7 days
                        • Advance diet as tolerated
                        • Plan definitive treatment
                        • Cholecystectomy if gallstone etiology
                        1. ✓

                           Outcome

                           Cholangitis Resolved

                           Plan interval cholecystectomy within 2-4 weeks if gallstone etiology

                        2. ✓

                           Outcome

                           Surgical Drainage

                           If endoscopic and percutaneous fail - open or laparoscopic CBD exploration

                  2. ●

                     Action

                     PTC/PTBD

                     Percutaneous Transhepatic Cholangiography

                     • If ERCP fails or not available
                     • Altered anatomy (Roux-en-Y, etc.)
                     • External or internal-external drain
                  3. ●

                     Action

                     EUS-Guided Drainage

                     Alternative if ERCP fails

                     • EUS-guided choledochoduodenostomy
                     • EUS-guided hepaticogastrostomy
                     • Requires expertise
            2. ●

               Action

               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
            3. ⚠

               Warning

               ⚠️ 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