a brief Tokyo Guideline 2018 for intern

1. ACUTE CHOLANGITIS: TOKYO
GUIDELINE 2018 IN BRIEF
FACEBOOK: HAPPY FRIDAY KNIGHT, MD, FRCST
9TH DECEMBER 2019
THAILAND

2. OUTLINES
• DEFINITION AND DIAGNOSTIC CRITERIA FOR ACUTE CHOLANGITIS
• SEVERITY ASSESSMENT
• MANAGEMENT:
• GENERAL MANAGEMENT
• ANTIBIOTICS
• BILIARY DRAINAGE: INDICATIONS AND TECHNIQUES

3. DEFINITION OF ACUTE CHOLANGITIS
• BILIARY STENOSIS ELEVATE BILIARY PRESSURE  FLUSH
ENDOTOXIN/MICROORGANISMS  BILIARY INFECTION
• CAUSES: BENIGN OR MALIGNANT
• BENIGN: STRICTURE, STONE, STENT
• MALIGNANT: CCA

5. DIAGNOSTIC CRITERIA
• REYNOLD’S PENTAD
• CHARCOT’S TRIAD + SHOCK + ALTER MENTAL STATUS
• NO MORE USE
• CHARCOT’S TRIAD
• FEVER, RUQ PAIN, JAUNDICE
• NO MORE USE

6. DIAGNOSTIC CRITERIA:
• SYSTEMIC INFLAMMATION
• FEVER (BT > 38OC)/SHAKING CHILLS
• LAB:
• WBC < 4000, > 10000 /MCL
• CRP ≥ 1 MG/DL
• CHOLESTASIS
• JAUNDICE: TB ≥ 2 MG/DL
• LAB: ABNORMAL LFT: INCREASES SERUM ALP, GGT, AST, ALT > 1.5 UPPER LIMIT OF NORMAL
VALUE
• IMAGING
• BILIARY DILATATION
• EVIDENCE OF ETIOLOGY ON IMAGING: STRICTURE, STONE, STENT ETC

7. IMAGING
• DIAGNOSTIC IMANGING CAN BE
• ULTRASOUND
• CT
• MRI/ MRCP
• PLAIN XRAY – NOT SUITED FOR DIAGNOSIS
• ERCP – FOR THERAPEUTIC NOT FIRST DX

8. ULTRASOUND
• NONINVASIVE
• COST-EFFECTIVE
• SHOULD BE PERFORMED FIRST
• LIMITATIONS
• OPERATOR DEPENDENCE
• BOWEL GAS

9. CT
• OBJECTIVES
• IDENTIFY BILIARY DILATAION, CAUSE
(EXCEPT (EXCEPT STONE), LOCAL
COMPLICATION (ABSCESS, PORTAL VEIN
THROMBOSIS)
• LIMITATION: LOW SENSITIVITY FOR
DETECTING STONE

10. MRCP
• NOT FIRST CHOICE

11. SEVERITY GRADING CRITERIA
• FOR MANAGEMENT PURPOSE
• GRADE III (SEVERE): ORGAN DYSFUNCTION 1 OF THE FOLLOWING:
• CARDIOVASCULAR: HYPOTENSION REQUIRE DOPAMINE/NOREPINEPHRINE
• NEUROLOGICAL: DISTURBANCE OF CONSCIOUSNESS
• RESPIRATORY: PF RATIO < 300
• RENAL: OLIGURIA, CR > 2 MG/DL
• HEPATIC: INR > 1.5
• HEMATOLOGIC: PLATELET < 100,000 /MM3

12. • GRADE II: ANY 2:
• WBC >12,000 OR <4,000
• FEVER ≥ 39OC
• AGE ≥ 75 YEARS OLD
• TB ≥ 5 MG/DL
• HYPOALBUMINEMIA < STD X 0.7
SEVERITY GRADING CRITERIA

13. • GRADE I: DOES NOT MEET CRITERIA SEVERE OR MODERATE
SEVERITY GRADING CRITERIA

14. MANAGEMENT OF ACUTE CHOLANGITIS
• ADEQUATE RESUSCITATION  FOLLOW SSC 2016 IF SEVERE
• ADEQUATE ANTIBIOTICS WITHIN 1 HOUR
• SOURCE CONTROL

16. INITIAL MANAGEMENT
• COLLECT VITAL SIGNS
• HISTORY TAKING AND PHYSICAL EXAMINATION: MURPHY’S SIGN
• LAB: CBC, BUN, CR, ELYTE, LFT, PT, PTT, INR, HEMOCULTURE
• IMAGING: US OR CT
• START IV FLUIDS, ANTIBIOTICS, ANALGESICS (USE MORPHINE WITH
CAUSTION DUE TO SPHINCTER OF ODDI SPASM)
• CAREFUL MONITORING OF BP, HR, URINE OUTPUT (RETAIN URINARY
CATHETER)
• IF SHOCK, FOLLOW SSC 2016

17. ANTIBIOTICS: WHICH ONE?
• MOST FREQUENT ORGANISM IS E.COLI (31-44%) AND KLEBSIELLA (9-
20%)
• IT CAN BE ANAEROBES (4-20%)

19. BILIARY DRAINAGE
• SURGICAL (OC WITH CBD EXPLORATION)
• PERCUTANEOUS TRANSHEPATIC (PTBD)
• ENDOSCOPIC TRANSPAPILLARY (ERCP WITH EBS OR ENBD)

25. ALT/ALP
• > 5  HEPATOCELLULAR
• 2 – 5  MIXED
• < 2  CHOLESTATIC INJURY