Acute cholangitis

Guidelines for diagnosis and severity grading of acute cholangitis[1]Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. https://onlinelibrary.wiley.com/doi/full/10.1002/jhbp.512 http://www.ncbi.nlm.nih.gov/pubmed/29032610?tool=bestpractice.com

Diagnostic criteria for acute cholangitis:

• A. Systemic inflammation

  • A-1. Fever (>38°C) and/or shaking chills

  • A-2. Laboratory data: evidence of inflammatory response (WBC <4 × 1000/microlitre, or WBC >10 × 1000/microlitre, or CRP ≥17 mmol/L [≥1 mg/dL]).

• B. Cholestasis

  • B-1. Jaundice (total bilirubin ≥34 micromol/L [≥2 mg/dL])

  • B-2. Laboratory data: abnormal liver function tests (>1.5 x upper limit of normal values for serum alkaline phosphatase, gamma-guanosine triphosphate [gamma-glutamyl transferase], AST and ALT levels).

• C. Imaging

  • C-1. Biliary dilation

  • C-2. Evidence of the aetiology on imaging (stricture, stone, stent).

• Suspected diagnosis: one item in A, plus one item in either B or C.

• Definite diagnosis: one item in A, plus one item in B, plus one item in C.

• Other helpful factors in diagnosing acute cholangitis include right upper quadrant or upper abdominal pain, a history of biliary disease such as gallstones, previous biliary procedures, and placement of a biliary stent.

• In acute hepatitis, marked systemic inflammatory response is observed infrequently. Virological and serological tests are required when differential diagnosis is difficult.

Severity assessment criteria for acute cholangitis:

• Grade III (severe) acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction in at least one of any of the following organs/systems:

  • Cardiovascular dysfunction: hypotension requiring dopamine ≥5 mg/kg per minute, or any dose of noradrenaline (norepinephrine)

  • Neurological dysfunction: disturbance of consciousness

  • Respiratory dysfunction: PaO2/FiO2 ratio <300

  • Renal dysfunction: oliguria, serum creatinine >177 micromol/L (>2 mg/dL)

  • Hepatic dysfunction: PT-INR >1.5

  • Haematological dysfunction: plt count <100 × 10⁹/L (<100,000/microlitre).

  Grade II (moderate) acute cholangitis is associated with any two of the following conditions:

  • Abnormal WBC count (>12 × 10⁹/L [>12,000/microlitre] or <4 × 10⁹/L [<4,000/microlitre])

  • High fever (≥39°C)

  • Age (≥75 years old)

  • Hyperbilirubinaemia (total bilirubin ≥85 micromol/L [≥5 mg/dL])

  • Hypoalbuminaemia (<70% of lower limit of normal).

  Grade I (mild) acute cholangitis meets no criteria of grade III (severe) or grade II (moderate) acute cholangitis at initial diagnosis.

  Early diagnosis, early biliary drainage and/or treatment for aetiology, and antimicrobial administration are fundamental treatments for acute cholangitis - not only for grade III (severe) and grade II (moderate) acute cholangitis, but also for grade I (mild). Therefore, it is recommended that patients with acute cholangitis who do not respond to the initial medical treatment (i.e., general supportive care and antimicrobial therapy) undergo early biliary drainage or treatment for aetiology.