Tokyo Guidelines for Acute Cholangitis 2018
Provides diagnostic criteria and severity grading for acute cholangitis.
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If a definitive diagnosis cannot be made on presentation, it is reasonable to reassess the patient using the diagnostic criteria every 6-12 hrs.
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In patients with grade I (mild) disease, if no response to the initial treatment is observed within 24 hr, perform biliary drainage immediately.
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In patients with grade II (moderate) or grade III (severe) disease, perform biliary drainage as soon as possible along with supportive care and antibiotics. Also, obtain blood cultures and bile cultures in such patients.
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Consider treating the etiology of acute cholangitis with endoscopic (endoscopic sphincterotomy or choledocholithotomy), percutaneous, or operative intervention once the acute illness has resolved. Cholecystectomy should be performed for gallstones after the acute cholangitis has resolved.
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Antibiotics should be chosen based on severity of disease, location of infection (community or hospital acquired), and local susceptibilities (see Tokyo Guidelines 2018 Antimicrobial Therapy for Acute Cholangitis and Cholecystitis).
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Upon diagnosis of acute cholangitis (regardless of severity) initial treatment generally consists of antibiotics, fluid resuscitation, electrolyte repletion, and appropriate analgesic administration.
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Grade I (mild):
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In most cases, initial treatment as above is sufficient, and most patients do not require biliary drainage.
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However, biliary drainage should be considered if a patient does not respond to initial treatment within 24 hrs.
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Grade II (moderate):
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Early (within 48 hrs of admission) endoscopic or percutaneous transhepatic biliary drainage is indicated.
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Grade III (severe):
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Treat underlying sepsis aggressively with respiratory (tracheal intubation) and circulatory (pressors) support.
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Emergent (as soon as patient is hemodynamically stable) endoscopic or percutaneous transhepatic biliary drainage is indicated.