Cholangitis diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Diagnostic criteria

An algorithm for diagnosis of cholangitis:[1][2]

 
 
 
 
 
 
 
 
 
Diagnosis of
acute cholangitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Definitive diagnosis

Signs of infection and pus finding in bile during:
ERCP
PTCA
•Surgery
 
 
 
 
 
Charcot triad
Fever
Jaundice
Abdominal pain

Reynold's pentad (includes 2 extra features)
Sepsis
Mental confusion
 
 
 
 
Tokyo guidelines 2013(TG 13)

A.Systemic inflammation
A-1. Fever and/or shaking chills
A-2. Laboratory data: evidence of inflammatory response

B.Cholestasis
B-1. Jaundice
B-2. Laboratory data: abnormal liver function tests

C.Imaging
C-1. Biliary dilatation
C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)

Suspected diagnosis: One item in A + one item in either B or C
Definite diagnosis: One item in A, one item in B and one item in C
Note: ERCP= Endoscopic retrograde cholangiopancreatography, PTCA =Percutaneous transhepatic cholangiography
A-2: Abnormal white blood cell counts, increase of serum C-reactive protein levels, and other changes indicating inflammation
B-2: Increased serum ALP, γGTP (GGT), AST and ALT levels.
Thresholds TG-13
Category Clinical/

Lab feature

Test/Units Value
A1 Fever Body temp >38° C
A2 Evidence of inflammatory response WBC (x1000μ/L) <4 or>10
CRP (mg/dl) ≥1
B1 Jaundice Total bilirubin

(mg/dL)

≥ 2
B2 Abnormal liver function test ALP (IU) >1.5 x STD
γGTP (IU) >1.5 x STD
AST (IU) >1.5 x STD
AST (IU) >1.5 x STD
STD=upper limit of normal value, ALP= alkaline phosphatase, γGTP (GGT)= γ-glutamyltransferase, AST= aspartate aminotransferase, ALT= alanine aminotransferase
  • An algorithm showing course of management:
 
 
 
 
 
 
 
 
 
Signs of acute cholangitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•Hospitalization
•IV fluids
•Broad spectrum antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement after hospitalization and/or hydration
and/or broad spectrum antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild cholangitis
 
 
 
 
 
 
 
Organ dysfunction present?
Hypotension
(which requires dobutamine or dopamine
@ 5μg/kg/min)
Confusion
•PaO2:FiO2 ratio<300
•Serum creatinine>177 μmol/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Elective ERCP and stone clearance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Moderate cholangitis
 
 
 
 
 
Severe cholangitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ERCP within 24-48 hours
•Stone clearance if stable
•Stent if unstable
 
 
 
 
 
Urgent ERCP and stent

References

  1. Lee, John G. (2009). "Diagnosis and management of acute cholangitis". Nature Reviews Gastroenterology & Hepatology. 6 (9): 533–541. ISSN 1759-5045. doi:10.1038/nrgastro.2009.126. 
  2. Kiriyama, Seiki; Takada, Tadahiro; Strasberg, Steven M.; Solomkin, Joseph S.; Mayumi, Toshihiko; Pitt, Henry A.; Gouma, Dirk J.; Garden, O. James; Büchler, Markus W.; Yokoe, Masamichi; Kimura, Yasutoshi; Tsuyuguchi, Toshio; Itoi, Takao; Yoshida, Masahiro; Miura, Fumihiko; Yamashita, Yuichi; Okamoto, Kohji; Gabata, Toshifumi; Hata, Jiro; Higuchi, Ryota; Windsor, John A.; Bornman, Philippus C.; Fan, Sheung-Tat; Singh, Harijt; de Santibanes, Eduardo; Gomi, Harumi; Kusachi, Shinya; Murata, Atsuhiko; Chen, Xiao-Ping; Jagannath, Palepu; Lee, Sung Gyu; Padbury, Robert; Chen, Miin-Fu; Dervenis, Christos; Chan, Angus C.W.; Supe, Avinash N.; Liau, Kui-Hin; Kim, Myung-Hwan; Kim, Sun-Whe (2013). "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)". Journal of Hepato-Biliary-Pancreatic Sciences. 20 (1): 24–34. ISSN 1868-6974. doi:10.1007/s00534-012-0561-3. 

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