CHOLANGITIS and flushes the microorganism or

endotoxins from the infected bile

Acute cholangitis: into systemic circulation
- Occurs when biliary stenosis due to: - Mortality risk: HIGH if condition is
o Presence of tumor not treated and biliary pressure is
o Bile duct stones not immediately reduced
- Biliary stenosis or blockage elevates DIAGNOSED with CHARCOT’s triad (very
pressure within the biliary system high specificity, low sensitivity):
1. Abdominal pain
2. Jaundice
3. Fever

Diagnostic imaging:
method to directly identify biliary
stenosis/blockage that can cause AC or to
describe cholangiectasis that can be used
as an indirect finding in support of a
diagnosis:
- Abdominal ultrasound: can readily
detect abnormal dilation of the bile
duct and can be used to identify the
cause
- CT scan: also useful in diagnosing
local complications (liver abscess or
portal vein thrombosis)
- MRCP: can delineate the bile duct
and is a good option for identifying
malignant disease or bile duct
stones causing a biliary obstruction
Endoscopic retrograde
cholangiopancreatography (ERCP) is
performed for the purpose of treatment
but is not suitable as 1st choice for
diagnostic purposes.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
FLOWCHART FOR THE INITIAL RESPONSE TO MANAGEMENT OF PATIENTS WITH
ACUTE BILIARY INFECTION SUSPECTED ACUTE BILIARY INFECTION

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
 - Vital signs: BP, HR, RR, Temp, urine a. Opioid analgesics (morphine
volume, oxygen saturation and hydrochloride), other non
consciousness level opioid analgesics and
- MURPHY’S SIGN: compression of the pentazocine: cause the
upper quadrant causes the patient sphincter of Oddi to contract,
to catch their breath due to pain which may elevate biliary
when taking a deep breath pressure and must therefore
o Specific to acute cholecystitis be administered with
caution.
TESTS REQUIRED FOR THE DIAGNOSIS OF 2. In the presence of shock,
ACUTE BILIARY INFECTION disturbance of consciousness, acute
- Blood tests: dyspnea, acute renal dysfunction,
o WBC hepatic dysfunction, or disseminated
o Plt intravascular coagulation
o CRP (DIC/reduced platelet)
o Albumin o Emergency biliary drainage
o ALP should be considered
o GGT o Organ and
o AST respiratory/circulatory
o ALT management
o BUN  Artificial ventilation
o Crea  Tracheal intubation
o PT/PTT  Use of hypertensive
agents
o Blood cultures: if with
 Antibiotics
presence of high fever
o Abdominal ultrasound:
MANAGEMENT OF ACUTE CHOLANGITIS
minimally invasive, widely
AND CHOLECYSTITIS
used, simple and cheap
- Grade I/mild acute cholangitis
Distinctive sign of acute cholecystitis on
o Antibiotics
diagnostic imaging include
o Most patietnts do not
- Enlargement of the gallbladder
require biliary drainage but
- Gallbladder wall thickening
should be considered if a
- Gallbladder calculi
patient does not respond to
- Fluid retention around the
initial treatment
gallbladder,
- Grade II/Moderate acute cholangitis
- Abscess around the gallbladder
o Not severe but requires early
- The sonographic Murphy’s sign
biliary drainage
INITIAL TREATMENT o Moderate cholangitis is
1. Infusion of sufficient fluids and assessed if at least 2 of the ff
antibiotic and analgesic 5 criteria are met:
administration.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
  WBC ≥ 12,000 or 
Neurological
<4000 dysfunction:
 Temp ≥ 39C disturbance of
 Age ≥ 75 yo consciousness
 Total bilirubin ≥  Respiratory
5mg/dl dysfunction:
 Albumin < lower limit PaO2/FiO2 ratio < 300
of the normal value x  Renal dysfunction:
0.73g/dl oliguria or serum
o Early endoscopic or creatinine >2.0mg/dl
percutaneous transhepatic  Hepatic dysfunction:
biliary drainage is indicated. PT-INR >1.5
- Grade III/ Severe acute cholangitis  Coagulation disorder:
o Sepsis induced organ plt count<104µl
damage o Appropriate
o Severe cholangitis is assessed respiratory/circulatory
if any one of the following management
criteria is met: o Endoscopic or percutaneous

 Cardiovascular transhepatic biliary drainage

dysfunction – should be performed
requiring the use of
dopamine ≥ 5µg/kg
per min or
noradrenaline

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
ANTIMICROBIAL THERAPY FOR ACUTE
CHOLANGITIS AND CHOLECYSTITIS

- Antimicrobial therapy is a mainstay

of the management for the patient
with acute cholangitis and/or
cholecystitis.
- The most frequently isolated
organism were Escherichia coli
across the severity grades

acute cholecystitis except those with

grade I severity.
 Blood cultures are not routinely
recommended for grade I
community-acquired acute
cholecystitis

What is the optimal duration and route of

antimicrobial therapy for patients with
acute cholangitis?
- Once the source of infection is
What specimen should be sent for culture controlled, antimicrobial therapy for
to identify the causative organism in acute patients with acute cholangitis is
cholangitis and cholecystitis? recommended for the duration of 4
- Bile cultures should be obtained at to 7 days.
the beginning of any procedure
performed. Gallbladder bile should
be sent for culture in all cases of

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
What is the optimal duration of WBC and without abdominal
antimicrobial therapy for patients with findings.
acute cholecystitis?
- Antimicrobial therapy for patients
with Grade I and II acute cholecytitis
is recommended only before and at
the time of surgery.
- Once the source of infection is
controlled, antimicrobial therapy for
patients with Grade III acute
cholecystitis is recommended for the
duration of 4 to 7 days.
- In patients with pericholecystic
abscess or perforation of the
gallbladder, treatment with an
antimicrobial regimen is listed in
table 3 is recommended. Therapy
should be continued until the
patient is afebrile, with a normalized

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
INDICATIONS AND TECHNIQUES OF BILIARY - Biliary stenting in patients with
DRAINAGE acute cholangitis who have
coagulopathy is more recommended
What is the most preferable biliary drainage - The approach to patients with acute
for acute cholangitis? cholangitis who are receiving
- Endoscopic transpapillary biliary antithrombotic agents must be
drainage for acute cholangitis: 1st selected according to the risks of
line drainage procedure because of bleeding and thromboembolism
its less invasiveness and lower risk of
adverse events than other drainage
techniques despite the risk of post
endoscopic retrograde
cholangiopancreatography (ERCP)
- Percutaneous transhepatic biliary
drainage (PTBD)/ Percutaneous
transhepatic cholangial drainage
(PTCD): useful alternative drainage
procedure
o Can be used as a salvage
therapy when conventional
endoscopic transpapillary
drainage has failed owing to
difficult selective biliary
cannulation.

Which is preferred procedure for acute

cholangitis associated with cholecholithisis?
Stone removal at a single session or at 2
sessions?
- Bile duct removal following
Endoscopic sphincterotomy (EST) at
a single session may be considered
in patients with mild or moderate
acute cholangitis.

What is the best approach to patients with

acute cholangitis who have coagulopathy or
are receiving antithrombotic agents? Biliary
stenting, endoscopuc papillary large balloon
dilatation (EPBD), or Endoscopic
sphincterotomy (EST)?

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis