Tokyo guideline 2013

R1

Tokyo guideline
First Guideline for acute cholangitis and
acute cholecystitis
2007, 2013
2013, 11 articles

TERMINOLOGY, ETIOLOGY AND

EPIDERMIOLOGY

Cholangitis
Definition
Morbid condition
Acute infection and inflammation in the bile duct

Cholangitis
Pathophysiology
Onset involve 2 factor
Increase bacteria in bile duct
intraductal pressure

Cholangitis
Historical
1887, Charcot use hepatic fever, Charcots triad
1959, Reynold and Dargan use Acute
obstructive cholangitis, Reynolds pentad
Longmires classification (not use)
Acute suppurative cholangitis ~ Charcot triad
Acute obstructive suppurative cholangitis ~ Reynolds
pentrad

Cholecystitis
Definition
Acute inflammation disease of Gall bladder

Cholecystitis
Pathophysiology

Gall stone => most common cause

Obstuction at GB neck or cystice duct
Increase GB pressure
=> acute cholecystitis
2 factor determine progression
Degree of ocstruction
Duration of obstructions

Cholecystitis
Pathophysiological classification
Edematous cholecystitis (1st stage, 2-4 day)
GB wall edema, interstitial fluid
Dilate capillaries and lymphatic

Cholecystitis
Pathophysiological classification
Necrotizing cholecystitis (2nd stage, 3-5 days)
Area of hemorrhage and necrosis

Cholecystitis
Pathophysiological
Suppurative cholecystitis (3rd stage, 7-10 dat)

WBC present at necrosis area

Repairing precess
GB begin contract ( fibrous proliferation)
Intramural absess, pericholecystic abscess present

Cholecystitis
Pathophysiological
Chronic cholecystitis
After repeated mild cholecystitis
Chronic irritation of large stone
Mucosal atrophy and fibrosis of GB wall

Cholecystitis
Special form of cholecysitis
Acalculous cholecystitis
Acute cholecystitis without stone

Xanthogranulomatous cholecystitis
Leakage of bile into GB
Rupture of Rokitansky-Anchoff sinus
Bile is ingest by histocytes, forming granuloma => foamy
histocyte

Cholecystitis
Special form of cholecysitis
Emphysematous cholecystitis
Infect by Gas-forming organism (C.perfringen)
Often in DM Pt
Likely progess sepsis and gangrenous GB

Torsion of GB
Inherite (floaing GB)
Aquired (aplanchnoptosis, senild hump back, scoliosis
and weight loss)
Physical factor (sudden change intraperitoneal
Pressure, body position, pendulum-like in antiflexion
position, hyperperistalsis, defecation, blow to the
abdomen

Cholecystitis
Advance form and type of complication

Perforate GB
Biliary peritonitis
Pericholecystic abscess
Biliary fistular

Epidermiology
Incidence in asymptomatic gall stone

Epidermiology
Incidence in asymptomatic gall stone

Much in first few years, decrease in next year

Epidermiology
Incidence of severe case of cholangitis

Shock 7-25%
Conscious disturbance 7-22%
Reynolds pentad 3.5-7.7%

Epidermiology
Incidence of severe case of cholecystitis

Epidermiology
After ERCP

Etiology
Acute cholangitis
Bileduct obstruction => cholestasis
Bacterial growth

Etiology
Acute cholangitis

Etiology
Acute cholangitis

Etiology
Acute cholecystitis

Acalculous cholecystitis 3.7-14%

Surgery, trauma, long ICU, infection, thermal
burn, parenteral nutrition

Etiology
Risk factor

4F or 5F => GS, not cholecystitis/cholangitis

Acute cholecystitis: Obese > non obese
cholelithiasis: 5.8 vs. 1.5 %, odds ratio [OR] = 4.9;
cholecystitis: 0.8 vs. 3.4 %, OR = 5.2

Etiology
Drug

Etiology
Other etiology of acute cholangitis
Mirizzi syndrome
Type I: compress from stone in GB neck and cysti duct
Type II: bililobiliary fistular

Lemmel syndrome
Duodenal parapapillary diverticulum
Compress bile duct

Prognosis
Mortality

Acute cholangitis
50% in 1980, 10-30% in 1981-1990, 2.7-10%
after 2000

Recurrence
After conservative treatment

Recurrence
After EST or EPBD

DIAGNOSIS AND SEVERITY

GRADING

Diagnosis and severity grading

for cholangitis
No standard criteria for diagnosis and
severity management

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis
CT or MRI for diagnosis (Level D
recommendation)
Serial CT: dynamic change
MRI: etiologic diagnosis

Diagnosis and severity grading

for cholangitis
Severeity
Mild: Charcots triad
Severe: Reynolds pentad
TG07
Grade I(mild): response to initial treatment
Grade II(moderate): no response to initial treatment
Grade III(severe): organ dysfunction

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholangitis

Diagnosis and severity grading

for cholecystitis
No diagnosis criteria and severity
assessment
Murphys sign
Specificity 79%-96%
Sensitivity 50-60%

TG07
Sensitivity 84.9%
Specificity 50%

TG13
Sensitivity 92.1%
Specificity 93.3%

Diagnosis and severity grading

for cholecystitis

Diagnosis and severity grading

for cholecystitis
U/S

Pericholecystic fluid
Sonographic Murphys sign (sen 63%
,spec93%)
Doppler sre useful (Lv C recommendation)

Diagnosis and severity grading

for cholecystitis
CT

Diagnosis and severity grading

for cholecystitis
HIDA scan
Higher specificity and accuracy than U/S

Diagnosis and severity grading

for cholecystitis
Severity
First present in the world by TG07
Grade III(Severe): organ dysfunction
Grade II(moderate): local inflamation to make
cholecystectomy difficult
Grade I(mild)

TG 13: no significant problem => no major

change

Diagnosis and severity grading

for cholecystitis

MANAGEMENT

Management
Cholangitis

Management
Cholecystitis

Manage bundle

Management bundle

ANTIMICROBIAL AGENT

Antimicrobial agent

Antimicrobial agent

INDICATION AND TECHNIQUE

FOR BILIARY DRAINAGE IN
CHOLANGITIS

Indication and technique for biliary

drainage in acute cholangitis

Less invasive

Indication and technique for biliary

drainage in acute cholangitis
PTBD
Second choice (following endospopic drainage)
Suggest in
Upper GI obstruction or surgically alter anatomy
Skilled endoscopist is not avaliable

Technique
U/S guide transhepatic puncture by 18-22G needle
Confirm backflow, guide wire
7-10 Fr catheter is place under fluoroscope

Success rate = 86% in biliary dilatation Pt

63% in without biliary dilatation Pt

Indication and technique for biliary

drainage in acute cholangitis
Endoscopic biliary drainage
Gold standard

Technique
Standard canulate or wire guide canulate, no
staistical significant difference
ENBD or EBS, no statistical significant difference,
ENBD is not suggest in poor compliance Pt

Indication and technique for biliary

drainage in acute cholangitis
Endoscopic sphincterotomy

Indication and technique for biliary

drainage in acute cholangitis
Endoscopic papillary balloon diatation
Use instead EST, no comparative study

Technique

After cannulation
Small balloon up to 8-mm insert into the bile duct
Dilate sphincter of Oddi
Clearance of stone by basket or balloon catheter

Indication and technique for biliary

drainage of acute cholecystitis

Indication and technique for biliary

drainage of acute cholecystitis
PTGBD

Indication and technique for biliary

drainage of acute cholecystitis
PTGBA

Indication and technique for biliary

drainage of acute cholecystitis
ENGBD

Indication and technique for biliary

drainage of acute cholecystitis
ENGBS

Indication and technique for biliary

drainage of acute cholecystitis
EUS-GBD

SURGICAL MANAGEMENT OF
ACUTE CHOECYSTITIS

Surgical management of acute

choecystitis

Surgical management of acute

choecystitis

Time for Cholecystectomy after PTGBD, lack

of any strong evidence, often several day
2wk

Thank you for your attention