Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital.

BACKGROUND: The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS: The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS: In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcot's triad (P<0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and 15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS: The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.

Comparison of two editions of Tokyo guidelines for the management of acute cholangitis.

BACKGROUND: The Tokyo guidelines from 2007 (TG07) and 2013 (TG13) were compared for the management of acute cholangitis (AC). METHODS: We reviewed patients with clinically-proven AC by detecting purulent biles during biliary drainage. TG07 and TG13 were compared regarding diagnosis, severity grading and prognostic values. New risk factors for 30-day mortality were investigated. RESULTS: Definite diagnosis for 120 eligible patients was made in 104 (86.7%) and 101 (84.2%) cases by TG07 and TG13, respectively (P = 0.36), higher than 61 (50.8%) by Charcot's triad (P < 0.001). Diagnostic overlap and concordance (κ) are 90.8% (109/120) and 0.63 (P < 0.0001). Patients classified into mild and moderate grades by TG07 and TG13 differed significantly (P = 0.043). Both guidelines could not predict clinical outcomes except the needs for multi ERCP session by TG13. Intrahepatic obstruction (OR = 11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤ 25.0 g/l; OR = 17.3, 95% CI: 3.5-313.6) were independent risk factors for 30-day mortality in multivariate model. CONCLUSION: Two guidelines are reproducible and reliable in AC diagnosis but different in severity grading. TG13 are more practical for immediate severity grading, enabling planning treatment upon admission. Intrahepatic obstruction is a new candidate predictor of 30-day mortality for further assessment.