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The Tokyo Guidelines for Cholangitis

The Tokyo Guidelines for Cholangitis. KP Tsui UNITED CHRISTIAN HOSPITAL. Cholangitis. Biliary infection associated with partial or complete obstruction of the biliary tree Diagnosis based on clinical findings, such as Charcot’s triad, with laboratory data and imaging findings.

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The Tokyo Guidelines for Cholangitis

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  1. The Tokyo Guidelines for Cholangitis KP Tsui UNITED CHRISTIAN HOSPITAL

  2. Cholangitis • Biliary infection associated with partial or complete obstruction of the biliary tree • Diagnosis based on clinical findings, such as Charcot’s triad, with laboratory data and imaging findings

  3. Charcot’s triad • Fever • Jaundice • Abdominal pain

  4. Reynold’s Pentad • + Hypotension • + Mental obtundation

  5. Lai EC, Tam PC, Paterson IA, Ng MM, Fan ST, Choi TK, et al. Emergency surgery for severe acute cholangitis. The high-risk patients. Ann Surg 1990;211:55–9.

  6. There was no standard criteria for the diagnosis and severity assessment

  7. Tokyo guidelines • Based on a systematic review of literature and consensus of experts at the International Consensus Meeting in Tokyo 2006

  8. TG07 Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg (2007) 14:52–58

  9. B-5: abnormal WBC, raised CRP and other changes indicating inflammation • B-6: raised ALP, r-GTP (GGT), AST and ALT levels

  10. Severity assessment criteria 2007 • Mild (grade I): acute cholangitis which responds to the initial medical treatment

  11. Moderate (grade II) acute cholangitis which does not respond to the initial medical treatment and is not accompanied by organ dysfunction

  12. TG07 Severity assessment criteria • Grade III (severe) • Associated with onset of dysfunction in at least one of the following organs/ systems

  13. Because of new information, the Tokyo Guidelines Revision Committee was organized to develop the update Tokyo guidelines (TG13)

  14. Multiple tertiary centers in Japan • From Jan 2007 and July 2011 • 794 patients with cholangitis

  15. Revision of TG07 • The diagnostic criteria was adjusted to achieve the highest sensitivity and specificity

  16. TG07 Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg (2007) 14:52–58

  17. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

  18. TG13 diagnostic criteria New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

  19. A-2: abnormal WBC, raised CRP and other changes indicating inflammation • B-2: raised ALP, r-GTP (GGT), AST and ALT levels

  20. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

  21. With suspected diagnosis, early biliary drainage and source control of infection can be provided

  22. Formulation of new severity assessment • TG07 insufficient in separating Grade I and Grade II • Need 24 hour observation period • Definition of grade II ambiguous

  23. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

  24. TG13 Severity assessment criteria • Grade III (severe) • Associated with onset of dysfunction in at least one of the following organs/ systems

  25. Grade II ( moderate ) • Any 2 of the following

  26. Grade I (mild) - Does not meet criteria for Grade II or Grade III at initial diagnosis

  27. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci (2013) 20:47–54

  28. TG13 management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci (2013) 20:55–59

  29. Tokyo guidelines • Minimal recognition outside Japan • Several retrospective studies have validated its diagnostic value Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  30. Tokyo guidelines 2007 • Based on Japanese studies • Sensitivity: 63.9-94% • Charcot’s triad < 40% Accuracy of the Tokyo Guidelines for the diagnosis of acute cholangitis and cholecystitis taking into consideration the clinical practice pattern in Japan. J Hepatobiliary Pancreat Sci 2011;18:250-257.

  31. Tokyo guidelines 2007 • Classification into mild or moderate grade using the Tokyo Guidelines is difficult when early biliary drainage is routinely performed. Journal of Hepato-Biliary-Pancreatic Sci, July 2012, Volume 19, Issue 4, pp 487-491. Verification of Tokyo Guidelines for diagnosis and management of acute cholangitis

  32. “Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital” Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  33. First study to verify the application of TG07 for diagnosis and treatment of cholangitis in Chinese patients Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  34. At Chinese PLA General Hospital, Beijing • 120 patients • 82 benign; 38 malignant • Retrospective from ERCP database

  35. Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  36. Definite diagnosis • 68 (82.9%) benign patients • 36 (94.7%) malignant • 104 (86.7%) overall • Charcot’s triad • 61 (50.8%) overall Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  37. Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  38. No significant difference in clinical outcome was observed in patients of different severity grades • Conclusion: The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

  39. Compliance • 60842 acute cholangitis patients from the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system. • Grade III: 7.6 ± 2.1 Grade II: 6.5 ± 3.0 Grade I: 2.9 ± 0.9, p < 0.001 (score 0 = 0% to score 10 = 100%) Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system. Journal of Hepato-Biliary-Pancreatic Sciences, January 2011, Volume 18, Issue 1, pp 53-59

  40. Improved prognosis of in-hospital mortality with odds ratio of 0.856 among patients with high compliance with the TG07

  41. Take home message • The Tokyo guidelines are more sensitive than Charcot’s triad for diagnosis of cholangitis • TG13 produces a new standard for diagnosis, severity grading and management of acute cholangitis • Awaiting further validation on TG13

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