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J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40. doi: 10.1002/jhbp.509. Epub 2018 Jan 8.

Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis.

Author information

1
Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
2
Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan.
3
Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
4
Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA.
5
Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
6
Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan.
7
Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
8
Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.
9
Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea.
10
Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
11
Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.
12
Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan.
13
Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan.
14
Clinical Surgery, University of Edinburgh, Edinburgh, UK.
15
Liau KH Consulting PL, Mt Elizabeth Novena Hospital, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
16
Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan.
17
Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan.
18
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
19
Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy.
20
First Department of Surgery, Agia Olga Hospital, Athens, Greece.
21
Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India.
22
Surgery Centre, Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong.
23
Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
24
Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
25
Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan.
26
Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina.
27
Chair of General Surgery and Minimal Invasive Surgery "Taquini", University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina.
28
Surgical Gastroenterology/Hepatopancreatobiliary Unit, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
29
Department of Hepato-Pancreato-Biliary Surgery, Hospital Selayang, Selangor, Malaysia.
30
Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
31
Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan.
32
Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
33
Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
34
Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
35
Department of Surgery, Jichi Medical University, Tochigi, Japan.
36
Director, Chiba Tokushukai Hospital, Chiba, Japan.
37
Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan.
38
Department of Surgery, Tohoku Rosai Hospital, Miyagi, Japan.
39
Department of Endoscopy and Ultrasound, Kawasaki Medical School, Okayama, Japan.
40
Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan.
41
Department of Gastroenterological and Pediatric Surgery, Oita University, Faculty of Medicine, Oita, Japan.
42
Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
43
Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan.
44
President, Oita University, Oita, Japan.
45
Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan.
46
Director, Toho University, Tokyo, Japan.
47
Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan.

Abstract

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

KEYWORDS:

Acute cholangitis; Acute cholecystitis; Biliary drainage; Guidelines; Initial treatment

PMID:
28941329
DOI:
10.1002/jhbp.509
[Indexed for MEDLINE]

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