TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis

109 Pages·2015·6.52 MB·English

JHepatobiliaryPancreatSci(2013)20:1–7
DOI10.1007/s00534-012-0566-y
GUIDELINE TG13: Updated Tokyo Guidelines for acute cholangitis
and acute cholecystitis
TG13: Updated Tokyo Guidelines for the management of acute
cholangitis and cholecystitis
TadahiroTakada • StevenM.Strasberg • JosephS.Solomkin • HenryA.Pitt • HarumiGomi • MasahiroYoshida •
Toshihiko Mayumi • Fumihiko Miura • Dirk J. Gouma • O. James Garden • Markus W. Bu¨chler •
Seiki Kiriyama • Masamichi Yokoe • Yasutoshi Kimura • Toshio Tsuyuguchi • Takao Itoi • Toshifumi Gabata •
Ryota Higuchi • Kohji Okamoto • Jiro Hata • Atsuhiko Murata • Shinya Kusachi • John A. Windsor •
Avinash N. Supe • SungGyu Lee • Xiao-Ping Chen • Yuichi Yamashita • Koichi Hirata • Kazuo Inui •
Yoshinobu Sumiyama
Publishedonline:11January2013
(cid:2)JapaneseSocietyofHepato-Biliary-PancreaticSurgeryandSpringer2012
Abstract In 2007, the Tokyo Guidelines for the man- presence of divergence between severity assessment and
agementofacutecholangitisandcholecystitis(TG07)were clinical judgment for acute cholangitis. In June 2010, we
firstpublishedintheJournalofHepato-Biliary-Pancreatic set up the Tokyo Guidelines Revision Committee for the
Surgery. The fundamental policy of TG07 was to achieve revision of TG07 (TGRC) and started the validation of
the objectives of TG07 through the development of con- TG07. We also set up new diagnostic criteria and severity
sensusamongspecialistsinthisfieldthroughouttheworld. assessment criteria by retrospectively analyzing cases of
Consideringsuchasituation,validationandfeedbackfrom acutecholangitisandcholecystitis,includingcasesofnon-
the clinicians’ viewpoints were indispensable. What had inflammatory biliary disease, collected from multiple
been pointed out from clinical practice was the low diag- institutions. TGRC held meetings a total of 35 times as
nostic sensitivity of TG07 for acute cholangitis and the well as international email exchanges with co-authors
abroad.OnJune9andSeptember6,2011,andonApril11,
T.Takada(&)(cid:2)F.Miura D.J.Gouma
DepartmentofSurgery,TeikyoUniversitySchoolofMedicine, DepartmentofSurgery,AcademicMedicalCenter,Amsterdam,
2-11-1Kaga,Itabashi-ku,Tokyo173-8605,Japan TheNetherlands
e-mail:[email protected]
O.J.Garden
S.M.Strasberg ClinicalSurgery,TheUniversityofEdinburgh,Edinburgh,UK
SectionofHepatobiliaryandPancreaticSurgery,Washington
UniversityinSaintLouisSchoolofMedicine,SaintLouis, M.W.Bu¨chler
MO,USA DepartmentofSurgery,UniversityofHeidelberg,
Heidelberg,Germany
J.S.Solomkin
DepartmentofSurgery,UniversityofCincinnatiCollegeof S.Kiriyama
Medicine,Cincinnati,OH,USA DepartmentofGastroenterology,OgakiMunicipalHospital,
Ogaki,Japan
H.A.Pitt
DepartmentofSurgery,IndianaUniversitySchoolofMedicine, M.Yokoe
Indianapolis,IN,USA GeneralInternalMedicine,NagoyaDainiRedCrossHospital,
Nagoya,Japan
H.Gomi
CenterforClinicalInfectiousDiseases,JichiMedicalUniversity, Y.Kimura
Tochigi,Japan DepartmentofSurgicalOncologyandGastroenterological
Surgery,SapporoMedicalUniversitySchoolofMedicine,
M.Yoshida Sapporo,Japan
ClinicalResearchCenterKakenHospital,International
UniversityofHealthandWelfare,Ichikawa,Japan T.Tsuyuguchi
DepartmentofMedicineandClinicalOncology,Graduate
T.Mayumi SchoolofMedicineChibaUniversity,Chiba,Japan
DepartmentofEmergencyandCriticalCareMedicine,
IchinomiyaMunicipalHospital,Ichinomiya,Japan
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2 JHepatobiliaryPancreatSci(2013)20:1–7
2012, weheldthreeInternationalMeetingsfortheClinical Keywords Acute cholangitis (cid:2) Acute cholecystitis (cid:2)
Assessment and Revision of Tokyo Guidelines. Through Charcot’s triad (cid:2) Biliary infection (cid:2) GRADE
thesemeetings,thefinaldraftoftheupdatedTokyoGuide-
lines(TG13)waspreparedonthebasisoftheevidencefrom
Background before Tokyo Guidelines 2007
retrospective multi-center analyses. To be specific, discus-
siontookplaceinvolvingtherevisednewdiagnosticcriteria,
Acute cholangitis and cholecystitis require appropriate
andthenewseverityassessmentcriteria,newflowchartsof
treatmentinthe acute phase. Severeacute cholangitis may
themanagementofacutecholangitisandcholecystitis,rec-
result in early death if no appropriate medical care is
ommendedmedicalcareforwhich newevidencehadbeen
provided in the acute phase. Before the publication of the
added, new recommendations for gallbladder drainage and
TokyoGuidelinesforthemanagementofacutecholangitis
antimicrobialtherapy,andtheroleofsurgicalintervention.
andcholecystitis(TG07)inJanuary2007[1],therewereno
Managementbundlesforacutecholangitisandcholecystitis
practical guidelines throughout the world primarily tar-
wereintroducedforeffectivedisseminationwiththelevelof
geting acute cholangitis and cholecystitis.
evidence and the grade of recommendations. GRADE sys-
TG07 had substantial influence on medical care for
temswereutilizedtoprovidethelevelofevidenceandthe
biliary infections throughout the world in that they clearly
grade of recommendations. TG13 improved the diagnostic
defined the diagnostic criteria and severity assessment
sensitivity for acute cholangitis and cholecystitis, and pre-
criteria for acute cholangitis and cholecystitis, the defini-
sented criteria with extremely low false positive rates
tion of which had until then been ambiguous. TG07 has
adapted for clinical practice. Furthermore, severity assess-
providedinternationalstandardsfordiagnosticandseverity
mentcriteriaadaptedforclinicaluse,flowcharts,andmany
assessment criteria. This has enabled the comparison and
new diagnostic and therapeutic modalities were presented.
integration of multiple studies (i.e., meta-analysis or sys-
The bundles for the management of acute cholangitis and
tematic reviews).
cholecystitisarepresentedinaseparatesectioninTG13.
TG07 was initially developed through the following
Free full-text articles anda mobile application ofTG13
processes. An international consensus meeting was held in
areavailableviahttp://www.jshbps.jp/en/guideline/tg13.html.
Tokyo on April 1 and 2, 2006. A total of 29 experts from
T.Itoi A.N.Supe
DepartmentofGastroenterologyandHepatology,Tokyo DepartmentofSurgicalGastroenterology,SethGSMedical
MedicalUniversity,Tokyo,Japan CollegeandKEMHospital,Mumbai,India
T.Gabata S.Lee
DepartmentofRadiology,KanazawaUniversityGraduate HepatoBiliarySurgeryandLiverTransplantation,AsanMedical
SchoolofMedicalScience,Kanazawa,Japan Center,UlsanUniversity,Seoul,Korea
R.Higuchi X.-P.Chen
DepartmentofSurgery,InstituteofGastroenterology,Tokyo DepartmentofSurgery,HepaticSurgeryCentre,
Women’sMedicalUniversity,Tokyo,Japan TongjiHospital,TongiMedicalCollege,
HuazhongUniverstyofScience&Technology,
K.Okamoto Wuhan,China
DepartmentofSurgery,KitakyushuMunicipalYahataHospital,
Kitakyushu,Japan Y.Yamashita
DepartmentofGastroenterologicalSurgery,FukuokaUniversity
J.Hata SchoolofMedicine,Fukuoka,Japan
DepartmentofEndoscopyandUltrasound,KawasakiMedical
School,Okayama,Japan K.Hirata
DepartmentofInternalMedicine,SecondTeachingHospital,
A.Murata FujitaHealthUniversitySchoolofMedicine,Nagoya,Aichi,
DepartmentofPreventiveMedicineandCommunityHealth, Japan
SchoolofMedicine,UniversityofOccupationaland
EnvironmentalHealth,Kitakyushu,Japan K.Inui
DepartmentofSurgeryI,SapporoMedicalUniversityHospital,
S.Kusachi Sapporo,Hokkaido,Japan
DepartmentofSurgery,TohoUniversityMedicalCenterOhashi
Hospital,Tokyo,Japan Y.Sumiyama
TohoUniversitySchoolofMedicine,Tokyo,Japan
J.A.Windsor
DepartmentofSurgery,TheUniversityofAuckland,Auckland,
NewZealand
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JHepatobiliaryPancreatSci(2013)20:1–7 3
22countriesandJapaneseexpertsinthisfieldattended the Table1 Summary of citations of TG07 (from January 2007 to
meeting. To obtain consensus, a voting system was used. December2011)
As the final product of this international consensus meet-
NumberofpapersinTG07citedatleastonce 14
ing, TG07 [2] was published in 2007.
Totalnumberoftimesofcitation 209
Theprocessofpreparationwasbynomeanseasy.TG07
NumberofarticlescitingpapersinTG07 122
was the world’s first clinical practice guidelines on the
NumberofjournalspublishingarticlescitingpapersinTG07 77
management of acute cholangitis and cholecystitis. There
were many obstacles to overcome. The preparation of
TG07 started according to the principle of evidence-based
medicine. However, due to the absence of diagnostic cri-
teria and severity assessment criteria, studies available at
that time were very few in number, and even if there was
extracted evidence, the criteria lacked unity and the con-
tents were often ambiguous. Furthermore, items to be
discussed included diagnostic methods and clinical deci-
sion-making such as the selection of antimicrobial agents
andtheirbiliarypenetration,therouteandtimingofbiliary
drainage, the timing of surgical intervention, and health-
care-associated (e.g., postoperative) cholangitis and cho-
lecystitis. It took an enormously long time to cover the Fig.1 AnnualnumberofcitationsofTG07
overall guidelines.
5.2
3.9
Citation analysis 2007–2011 of TG07 6.5
33.8
11.7
TG07 has been cited widely since its publication. The
numberofpaperscitingTG07[1,3–5]hasbeenincreasing 14.3
everyyear[6]andhasreachedapproximately209treatises.
Those treatises have been cited in textbooks of surgery,
internal medicine, and guidelines of abdominal infections
[7–9]. The significance of this is that TG07 has had sub-
stantial influence on medical education and has become
Fig.2 Categoriesofthejournalspublishingarticlescitingpapersin
disseminated throughout the world as a global standard.
TG07(n=77)
The results of the survey that examined the number of
citationsofTG07 untilDecember 2011 showthat the total
1.6
number of citations of TG07 was 209 in 2009 (Table 1). 1.6
The number of citations occurring each year since 2007 is 11.5
presented in Fig. 1.
32.8
23.8
The number of journals that cited TG07 was 77.
Figure 2providesabreakdownofthefieldsofthejournals
that cited TG07. 28.7
Therewere112treatisesthathadbeencitedfromTG07.
Figure 3 provides a breakdown of the residential areas of
theauthors.Table 2showsthetypesofarticleswhichcited
TG07. Of the 76 original treatises, 20 (26.3 %) were cited Fig.3 Geographical origin of authors citing papers in TG07
(n=122)
in method sections (Fig. 4). The citation of original trea-
tises inmethod sectionshas been onarapidincreasesince
2011(Fig. 5).Ofthetreatisescitedinthemethodsections, Need for revision of TG07
studies had been conducted in 17 titles concerning diag-
nostic criteria and/or severity assessment criteria (Fig. 4). 1. The development of evidence-based guidelines, clinical
In summary, TG07 has been cited in journals in various practice and assessment
fields throughout the world, although only 5 years’ cita- ThepublicationofTG07enabledthepresentationofthe
tions were totaled. firstinternationaldiagnosticcriteriaandseverityassessment
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4 JHepatobiliaryPancreatSci(2013)20:1–7
Table2 TypesofarticlescitingTG07 Develop Clinical Guidelines
Typesofarticles No.ofarticles Evidence and consensus based
Originalarticle 76(62.3%)
Review 20(16.4%) Publication and assessment
distribution
Casereport 11(9.0%)
Guideline 7(5.7%)
Others 8(6.6%)
Use Guidelines
Total 122
Fig.6 Evidence–practicecycle
In 17 articles, patients were diagnosed according to the diagnostic
criteria and severity assessment of TG. and therapeutic methods. Therefore clinical practice
guidelinesrequireregularupdateandrevision[12].Inview
ofthesecircumstances,anevidence-basedrevisionprocess
is also required for TG07. After its publication, an
appraisal from clinicians has been taking place concerning
dissemination/useand the results are being made good use
of for future revision (Fig. 6).
2. Validity of TG07
GiventhecriticalappraisalofTG07,thereareproblems
in applying it in clinical settings. First, the sensitivity of
Fig.4 Sectionwherecitedinoriginalarticles(n=76) acute cholangitis is low. Second, there are impractical
aspects in the severity assessment criteria for moderate
acute cholangitis such as deciding the timing of biliary
drainage. There were discordances between clinical
judgement by clinicians and the level of severity utilizing
TG07 severity assessment criteria.
Process of the development of Tokyo Guidelines 2013
(TG13)
1. The First International Meeting for the development of
TG13
On June 9, 2011, the first International Meeting for
Fig.5 AnnualnumberoforiginalarticlescitingpapersinTG07 ClinicalAssessmentandRevisionoftheTokyoGuidelines
washeld.Inthismeeting,itwasmadeclearthat:(1)TG07
criteria [1, 3–6] and, at the same time, the presentation of should be updated due to the presence of divergence
those criteria improved the quality of medical care betweenTG07andrealclinicalsettings;(2)thevalidityof
throughout the world, and the usefulness of TG07 has the diagnostic criteria for acute cholangitis was to be
become a target of appraisal from clinical viewpoints [10, investigated on the basis of retrospective analysis of
11]. TG07 should have been prepared primarily on the patients with acute cholangitis collected from multiple
basisofevidence.However,duetothepaucityofevidence, institutions; (3) there was divergence between severity
it was completed through combining ‘‘best available evi- assessment and clinical judgement for acute cholangitis.
dence’’ and the worldwide knowledge cultivated at the 2. The Second International Meeting for the develop-
international consensus meeting. Therefore, a test by cli- ment of TG13
nicians for its usefulness is indispensable. TG07 has now On September 6, 2011, the Second International Meet-
reached the stage when it can be further improved on the ing for Clinical Assessment and Revision of the Tokyo
basis of evidence and consensus as well as feedback from Guidelines was held. At the meeting, the overall action
clinical practice. plansforthenewguidelinesweredeterminedwiththedraft
Ingeneral,followingthepublicationofclinical practice revision of the TG07 and the newly introduced Grades of
guidelines, newfindingsare reportedconcerningdiagnosis Recommendation,Assessment,DevelopmentandEvaluation
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JHepatobiliaryPancreatSci(2013)20:1–7 5
(GRADE) systems to provide the levels of evidence and the quality of the study was re-assessed based on the lim-
grade of recommendations. In this meeting, antimicrobial itations and the body of evidence was re-classified as
therapy was mainly discussed. Using the two international ‘‘moderate’’ evidence. Observational studies (a non-ran-
meetings mentioned above as a basis, the revision work of domizedstudy,acohortstudy,oracase–controlstudy)are
TG07 started in 2011. classified as having low-level evidence in general. The
3. The validation study for acute cholangitis was pre- bodyofevidencemaybeupgradedto‘‘highlevel’’ifithas
sented in Kiriyama et al.’s paper [13]. significant influences in clinical practice. Case series or
4. The clinical study for Charcot’s triad was also case reports are classified as having very low evidence, in
described in Kiriyama et al.’s paper [13]. general. It is extremely rare that the body of evidence is
5. The validation study for acute cholecystitis was pre- re-classifiedtoahigherlevel.However,reportsofcasesof
sented in Yokoe et al.’s paper [14]. deaths due to complications or cases of significant side
6. Third International Meeting for the development of effects may be considered as a higher level.
TG13 The strength of recommendations was classified as
On April 11, 2012, the Third International Meeting for ‘‘high (strong)’’ (recommendation 1) and ‘‘low (weak)’’
the Clinical Assessment and Revision of Tokyo Guide- (recommendation 2). Four factors that determine the
lines was held. In this meeting, the final draft of the strength of recommendations are: (1) the quality of evi-
updated Tokyo Guidelines was prepared on the basis of dence; (2) sense of value and patient’s preference (less
the evidence from the validation studies of TG07. To burden on staff members and patients); (3) net profits and
begin with, a discussion took place involving the updated cost/source(costsaving);and(4)benefitsandharmburden
new diagnostic criteria for which sensitivity and speci- (benefits and risks). The general decision was made by
ficity had been improved, the new severity assessment taking into account these four factors. Strong and weak
criteria adapted for practical medical care, new flowcharts recommendations were then determined by the Tokyo
prepared for reducing divergence between evidence and GuidelinesRevisionCommittee.Astrongrecommendation
clinical care, recommended medical care to which new suggests that desirable effects clearly exceed undesirable
evidence had been added, the new idea of gallbladder effects and is applied to recommendations on which more
drainage and biliary drainage methods in clinical use, than 70 % of the members of the Tokyo Guidelines
antimicrobial therapy, and the role of surgical Revision Committee have agreed. The use of ‘‘We rec-
intervention. ommend …’’ has been adopted for the style of the
The concept and methodology of management bundles expression. A weak recommendation shows that desirable
was introduced and discussed as tools for the effective effects probably exceed undesirable effects and the use of
dissemination and implementation of clinical practice ‘‘We suggest …’’ has been adopted.
guidelines by utilizing the GRADE systems for evidence The recommendation 1 level A (strong recommenda-
assessment, and the concept of the grade of recommenda- tion;evidencelevelhigh),1B,1C,1D,2A,2B,2C,and2D
tion. As the results of the Third International Meeting for (weak recommendation; evidence level very low) are
theClinicalAssessmentandRevisionofTokyoGuidelines, shown at the end of recommendations. However, cases
the final draft was prepared through an international email with strong recommendation (recommendation 1) may
conference with overseas co-authors. Thus TG13 was include those cases for which ‘‘to perform …’’ is strongly
formulated. recommended and those for which ‘‘not to perform …’’ is
strongly recommended.
The GRADE systems
Introduction of bundles for the management of acute
The assessment of the evidence and the grading of rec- cholangitis and cholecystitis
ommendations in TG13 are based on the GRADE systems
reported in 2004 and 2008 by the working team for the Wepresentedanddiscussedtheconceptandthemethodof
GRADE [15–17]. The assessment of the quality of evi- management bundles in TG13. Concrete objectives and
dence and the strength of recommendation are shown in anticipated effects of the bundles are as follows: (1) to
Figs. 7 and 8), respectively. achieve improved prognosis by using bundles of treatment
Intheassessmentofthequalityofevidence,thelevelof methodswithevidencepresentedintheguidelines(TG13);
evidence is classified as ‘‘high’’ (level A), ‘‘moderate’’ (2) to achieve higher compliance and remove barriers
(level B), ‘‘low’’ (level C), or ‘‘very low’’ (level D). A among institutions by presenting a list of guidelines in the
randomized trial is, in general, classified as having high- form of bundles; (3) to carry out a survey involving com-
level evidence. However, due to limitations in each study, pliancewiththeitemsofthemedicalcarerecommendedby
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6 JHepatobiliaryPancreatSci(2013)20:1–7
Fig.7 GRADEsystem(quality
Initial quality of Study design Lower if Higher if
ofevidence)[15–17]
evidence
High RCT, systematic Study limitations: Magnitude of effect:
review, meta- 1 Serious 2 Very strong
analysis 2 Very serious 1 Strong
Inconsistency:
Moderate
1 Serious Dose-response
2 Very serious gradient
Low Observational
Indirectness: 1
study
1 Serious
(cohort study, case
2 Very serious All plausible
control study
Impression: confounders would
Very low Any other 1 Serious have reduced the
evidence 2 Very serious effect
(case series, case Publication bias 1
study) 1 likely
2 Very likely
Definition: Overall quality of evidence across studies for the outcome
level A High level B Moderate level C Low level D Very low
1. How to judge a Grade of recommendation References
Totally judgment with evidence, harm and benefit
Level of evidence A, B, C, D 1. Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T,
SekimotoM,etal.Background:TokyoGuidelinesfortheman-
Patient’spreference Yes, No
agement of acute cholangitis and cholecystitis. J Hepatobiliary
Harm and benefit Yes, No
PancreatSurg.2007;14:1–10.
Cost effectiveness Yes, No 2. Tokyo Guidelines for the management of acute cholangitis and
2. How to show a Grade of recommendation 2steps cholecystitis. Proceedings of a consensus meeting, April 2006,
Recommendation 1: Strong recommendation(Do it, Don’t do it): Tokyo,Japan.JHepato-BiliaryPancreatSurg.2007;14:1–121.
3. MiuraF,TakadaT,KawaradaY,NimuraY,WadaK,HirotaM,
Over 70 of clinical practitioners will agree
et al. Flowcharts for the diagnosis and treatment of acute cho-
= We recommend
langitis and cholecystitis: Tokyo guidelines. J Hepatobiliary
Recommendation 2 Weak recommendation (probably do it, PancreatSurg.2007;14:27–34.
probably don’t do it) 4. Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida
Less than 70 will agree = We suggest M, et al. Diagnostic criteria and severity assessment of acute
cholangitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg.
Fig.8 GRADEsystem(gradeofrecommendation)[15–17] 2007;14:52–8.
5. HirotaM,TakadaT,KawaradaY,NimuraY,MiuraF,HirataK,
et al. Diagnostic criteria and severity assessment of acute cho-
the guidelines and to provide guidelines for conducting a lecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg.
surveyconcerningchangesinmedicalcarebeforeandafter 2007;14:78–82.
6. Strasberg SM. Acute calculous cholecystitis. N Engl J Med.
publication of TG13.
2008;358:2804–11.
7. Cameron JL, Cameron AM. Current surgical therapy. 10th ed.
ElsevierMosby:Philadelphia.2011;p.345–348.
Summary 8. DooleyJS,LokA,BurroughsA,HeathcoteJ.Sherlock’sdiseases
of the liver and biliary system, 12th ed. Blackwell: Hoboken;
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9. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein
impact since publication, the clinical appraisal emerging EJ, Baron EJ, et al. Diagnosis and management of complicated
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ofAmerica.ClinicalInfectDis.2010;50(2):133–64.
evaluation and revision. TG13 has been developed to
10. Murata A, Matsuda S, Kuwabara K, Fujino Y, Kubo T, et al.
improvethequalityofmedicalcareforpatientswithacute Evaluation of compliance with the Tokyo Guidelines for the
cholangitis and cholecystitis. The guidelines should be management of acute cholangitis based on the Japanese admin-
istrative database associated with the Diagnosis Procedure
widely utilized and prospective clinical studies are needed
Combinationsystem.JHepatobiliaryPancreatSci.2010;18:53–9.
for further improvement in the near future.
11. Yokoe M, Takada T, Mayumi T, Yoshida M, Hasegawa H,
Norimizo S, et al. Accuracy of the Tokyo Guidelines for the
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JHepatobiliaryPancreatSci(2013)20:8–23
DOI10.1007/s00534-012-0564-0
GUIDELINE TG13: Updated Tokyo Guidelines for acute cholangitis
and acute cholecystitis
TG13 current terminology, etiology, and epidemiology of acute
cholangitis and cholecystitis
YasutoshiKimura • TadahiroTakada • StevenM.Strasberg • HenryA.Pitt • DirkJ.Gouma • O.JamesGarden •
Markus W. Bu¨chler • John A. Windsor • Toshihiko Mayumi • Masahiro Yoshida • Fumihiko Miura •
Ryota Higuchi • Toshifumi Gabata • Jiro Hata • Harumi Gomi • Christos Dervenis • Wan-Yee Lau •
Giulio Belli • Myung-Hwan Kim • Serafin C. Hilvano • Yuichi Yamashita
Publishedonline:11January2013
(cid:2)JapaneseSocietyofHepato-Biliary-PancreaticSurgeryandSpringer2012
Abstract While referring to the evidence adopted in the cholecystitis is the presence of stones. Next to stones, the
Tokyo Guidelines 2007 (TG07) as well as subsequently most significant etiology of acute cholangitis is benign/
obtained evidence, further discussion took place on ter- malignant stenosis of the biliary tract. On the other hand,
minology,etiology,andepidemiologicaldata.Inparticular, there is another type of acute cholecystitis, acute acalcu-
new findings have accumulated on the occurrence of lous cholecystitis, in which stones are not involved as
symptoms in patients with gallstones, frequency of severe causative factors. Risk factors for acute acalculous chole-
cholecystitis and cholangitis, onset of cholecystitis cystitis include surgery, trauma, burn, and parenteral
and cholangitis after endoscopic retrograde cholangiopan- nutrition.After2000,themortalityrateofacutecholangitis
creatography and medications, mortality rate, and recur- has been about 10 %, while that of acute cholecystitis has
rence rate. The primary etiology of acute cholangitis/ generally been less than 1 %. After the publication of
TG07, diagnostic criteria and severity assessment criteria
were standardized, and the distribution of cases according
Electronicsupplementarymaterial Theonlineversionofthis to severity and comparison of clinical data among target
article(doi:10.1007/s00534-012-0564-0)containssupplementary
populations have become more subjective. The concept of
material,whichisavailabletoauthorizedusers.
Y.Kimura(&) M.W.Bu¨chler
DepartmentofSurgicalOncologyandGastroenterological DepartmentofSurgery,UniversityofHeidelberg,Heidelberg,
Surgery,SapporoMedicalUniversitySchoolofMedicine, Germany
S-1,W-16,Chuo-ku,Sapporo060-8543,Japan
e-mail:[email protected] J.A.Windsor
DepartmentofSurgery,TheUniversityofAuckland,Auckland,
T.Takada(cid:2)F.Miura NewZealand
DepartmentofSurgery,TeikyoUniversitySchoolofMedicine,
Tokyo,Japan T.Mayumi
DepartmentofEmergencyandCriticalCareMedicine,
S.M.Strasberg IchinomiyaMunicipalHospital,Ichinomiya,Japan
SectionofHepatobiliaryandPancreaticSurgery,Washington
UniversityinSaintLouisSchoolofMedicine, M.Yoshida
SaintLouis,MO,USA ClinicalResearchCenterKakenHospital,International
UniversityofHealthandWelfare,Ichikawa,Japan
H.A.Pitt
DepartmentofSurgery,IndianaUniversitySchoolofMedicine, R.Higuchi
Indianapolis,IN,USA DepartmentofSurgery,InstituteofGastroenterology,
TokyoWomen’sMedicalUniversity,Tokyo,Japan
D.J.Gouma
DepartmentofSurgery,AcademicMedicalCenter,Amsterdam, T.Gabata
TheNetherlands DepartmentofRadiology,KanazawaUniversityGraduate
SchoolofMedicalScience,Kanazawa,Japan
O.J.Garden
ClinicalSurgery,TheUniversityofEdinburgh,Edinburgh,UK
123
JHepatobiliaryPancreatSci(2013)20:8–23 9
healthcare-associated infections is important in the current mortality rate, and recurrence rate are introduced along
treatment of infection. The treatment of acute cholangitis with epidemiological data.
and cholecystitis substantially differs from that of com-
munity-acquired infections. Cholangitis and cholecystitis
as healthcare-associated infections are clearly described in Terminology
the updated Tokyo Guidelines (TG13).
Free full-text articles anda mobile application ofTG13 Acute cholangitis
are available via http://www.jshbps.jp/en/guideline/tg13.
html. Definition
Keywords Terminology (cid:2) Etiology (cid:2) Epidemiology (cid:2) Acute cholangitis is a morbid condition with acute
Acute cholangitis (cid:2) Acute cholecystitis inflammation and infection in the bile duct [1, 2].
Pathophysiology
Introduction
The onset of acute cholangitis involves two factors: (1)
Acute biliary infection comprises manifold disease con- increased bacteria in the bile duct, and (2) elevated intra-
cepts and is mostly separated into [1] acute cholangitis, a ductal pressure in the bile duct allowing translocation of
systemic infectious disease that is occasionally life-threat- bacteria or endotoxin into the vascular and lymphatic
ening and requires immediate treatment, and [2] acute system(cholangio-venous/lymphaticreflux).Becauseofits
cholecystitis, frequently presentinga mild clinical course. anatomicalcharacteristics,thebiliarysystemislikelytobe
The definition, pathophysiology, and epidemiology of affected by the elevated intraductal pressure. In acute
acutecholangitisarepresentedintheTokyoGuidelinesfor cholangitis, bile ductules tend to become more permeable
the management of acute cholangitis and chlecystitis 2007 tothetranslocationofbacteriaandtoxinswiththeelevated
(TG07) [1], while the updated Tokyo Guidelines (TG13) intraductal biliary pressure. This process results in serious
present more subjective data acquired throughout the and fatal infections such as hepatic abscess and sepsis [1].
revisionofTG07.Asforthedataofcurrentclinicaltrialsin
particular, the data concerning frequency of severe cases, Historical aspect of terminology
J.Hata Signs of hepatic fever Hepatic fever was a term used for
DepartmentofEndoscopyandUltrasound,KawasakiMedical
thefirsttimebyCharcotinhisreportpublishedin1887[3].
School,Okayama,Japan
Intermittent fever accompanied by chills, right upper
H.Gomi quadrant abdominal pain, and jaundice have been estab-
CenterforClinicalInfectiousDiseases,JichiMedicalUniversity, lished as Charcot’s triad.
Tochigi,Japan
Acute obstructive cholangitis Acute obstructive cholan-
C.Dervenis
FirstDepartmentofSurgery,AgiaOlgaHospital,Athens, gitiswasdefinedbyReynoldsandDargan[4]in1959asa
Greece syndrome consisting of lethargy or mental confusion and
shock, as well as fever, jaundice, and abdominal pain
W.-Y.Lau
caused by biliary obstruction. They indicated that emer-
FacultyofMedicine,TheChineseUniversityofHongKong,
HongKong,HongKong gency surgical biliary decompression was the only effec-
tive procedure for treating the disease. These five
G.Belli
symptoms were thus called Reynold’s pentad.
GeneralandHPBSurgery,LoretoNuovoHospital,Naples,Italy
M.-H.Kim Longmire’s classification Longmire classified patients
DepartmentofInternalMedicine,AsanMedicalCenter, withthreecharacteristicsofintermittentfeveraccompanied
UniversityofUlsan,Seoul,Korea
by chills and shivering, right upper quadrant abdominal
pain, and jaundice as acute suppurative cholangitis, and
S.C.Hilvano
DepartmentofSurgery,CollegeofMedicine-PhilippineGeneral those with lethargy or mental confusion and shock along
Hospital, UniversityofthePhilippines,Manila,Philippines with the triad as acute obstructive suppurative cholangitis
(AOSC). He also reported that the latter corresponded to
Y.Yamashita
themorbidityofacuteobstructivecholangitisasdefinedby
DepartmentofGastroenterologicalSurgery,FukuokaUniversity
SchoolofMedicine,Fukuoka,Japan Reynolds [5].
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10 JHepatobiliaryPancreatSci(2013)20:8–23
However, terms such as acute obstructive cholangitis Pathological classification
and acute obstructive suppurative cholangitis (AOSC) are
not appropriate as current clinical terminology because (1) Edematous cholecystitis: 1st stage (2–4 days) The
their definition is conceptual and ambiguous. gallbladder has interstitial fluid with dilated capillar-
ies and lymphatics. The gallbladder wall is edema-
Acute cholangitis/cholecystitis as healthcare-associated tous. Gallbladder tissue is intact histologically with
infections edema in the subserosal layer [1].
(2) Necrotizing cholecystitis: 2nd stage (3–5 days) The
In the US IDSA/SIS guidelines on abdominal infection, gallbladder has edematous changes with areas of
acute cholangitis/cholecystitis refers to biliary tract infec- hemorrhage and necrosis. When the gallbladder wall
tion that has developed in any of the following patients: issubjecttoelevatedinternalpressure,thebloodflow
patientswithahistoryoflessthan12 monthshospitalstay, is obstructed with histological evidence of vascular
patients undergoing dialysis, patients staying at nursing thrombosisandocclusion.Thereareareasofscattered
home/rehabilitation facility, and patients in an immune- necrosis but they are superficial and do not involve
compromised state [6]. the full thickness of the gallbladder wall [1] (Fig. 1).
That concept has been extrapolated, and acute cho-
langitis/cholecystitisasahealthcare-associatedinfection
inJapanreferstoinfectionthathasdevelopedinpatients a
(long-term recumbency, admission to nursing home,
gastrostomy, tracheostomy, repeated aspiration pneu-
monia,bedsore,uretheralcatheterplacement,historyof
recent postoperative infection, or undergoing antimi-
crobial therapy due to other diseases) at risk of having
resistant bacteria (bacteria with a high minimum inhib-
itory concentration, MIC). Those infections should
be treated independently from community-required
infections.
Acute cholecystitis
Definition
b
Acute inflammatory disease of the gallbladder, often
attributable to gallstones, but many factors, such as ische-
mia, motility disorders, direct chemical injury, infections
by microorganism, protozoon and parasites, collagen dis-
ease, and allergic reaction are also involved [1].
Pathophysiology
In the majority of patients, gallstones are the cause of
acute cholecystitis. The process is one of physical
obstruction of the gallbladder at the neck or in the cystic
duct by a gallstone. This obstruction results in increased
pressure in the gallbladder. There are two factors which
determine the progression to acute cholecystitis—the
degree of obstruction and the duration of the obstruction.
Fig.1 Necrotizing cholecystitis. a Contrast-enhanced CT images
If the obstruction is partial and of short duration, the
show discontinuity of the gallbladder wall, suggesting possible
patient experiences biliary colic. If the obstruction is presence of necrosis in a portion of the wall. b Resected specimen
complete and of long duration, the patient develops acute showing extensive falling-off of the gallbladder membrane, erosion,
ulcer,andexposedfascia.Histologically,necrosisofthegallbladder
cholecystitis. If the patient does not receive early treat-
wall and suppurative inflammation accompanying abscess (data not
ment, the disease becomes more serious and complica-
shown)wereobservedwithfibrillationandregeneratinghyperplastic
tions can occur [1]. epitheliumasbackground
123