Tokyo Guidelines 2018 (Acute Cholangitis / Cholecystitis)

Tokyo Guidelines 2018 (TG18) — Acute Cholangitis / Cholecystitis

Applies the Tokyo Guidelines 2018 (TG18/TG13) criteria to diagnose and grade severity of acute cholangitis and acute cholecystitis from clinician-applied Yes/No findings.

Disease being assessed

Acute cholangitis criteria (used when disease = acute cholangitis)

[A-1] Fever (body temperature > 38 °C) and/or shaking chills

[A-2] Inflammatory labs: WBC < 4,000 or > 10,000 /mm3, and/or CRP ≥ 1 mg/dL

[B-1] Jaundice: total bilirubin ≥ 2 mg/dL

[B-2] Abnormal LFT: ALP / GGT / AST / ALT > 1.5x ULN (any one)

[C-1] Imaging: biliary dilatation

[C-2] Imaging: evidence of the etiology (stricture, stone, stent, etc.)

[Grade II] Abnormal WBC count: > 12,000/mm3 OR < 4,000/mm3

[Grade II] High fever: temperature ≥ 39 °C

[Grade II] Age ≥ 75 years

[Grade II] Hyperbilirubinemia: total bilirubin ≥ 5 mg/dL

[Grade II] Hypoalbuminemia: serum albumin < 0.7x STD

Acute cholecystitis criteria (used when disease = acute cholecystitis)

[A] Local signs: Murphy’s sign OR RUQ mass / pain / tenderness

[B] Systemic signs: fever OR elevated CRP OR elevated WBC count

[C] Imaging findings characteristic of acute cholecystitis

[Grade II] Elevated WBC count > 18,000/mm3

[Grade II] Palpable tender mass in the right upper abdominal quadrant

[Grade II] Duration of complaints > 72 hours

[Grade II] Marked local inflammation (gangrenous / abscess / peritonitis / emphysematous)

Grade III organ dysfunction (required for both diseases)

Cardiovascular: hypotension requiring dopamine ≥ 5 µg/kg/min OR any dose of norepinephrine

Neurological: disturbance / decreased level of consciousness

Respiratory: PaO2/FiO2 ratio < 300

Renal: oliguria OR serum creatinine > 2.0 mg/dL

Hepatic: PT-INR > 1.5

Hematological: platelet count < 100,000/mm3