Cholangitis diagnostic criteria: Difference between revisions

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Latest revision as of 16:01, 15 December 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Diagnostic criteria

An algorithm for diagnosis of cholangitis:^[1]^[2]

Diagnosis of
acute cholangitis

Definitive diagnosis

Signs of infection and pus finding in bile during:
•ERCP
•PTCA
•Surgery

Charcot triad
•Fever
•Jaundice
•Abdominal pain

Reynold's pentad (includes 2 extra features)
•Sepsis
•Mental confusion

Tokyo guidelines 2013(TG 13)^‡

A.Systemic inflammation
A-1. Fever and/or shaking chills
A-2. Laboratory data: evidence of inflammatory response

B.Cholestasis
B-1. Jaundice
B-2. Laboratory data: abnormal liver function tests

C.Imaging
C-1. Biliary dilatation
C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)

Suspected diagnosis: One item in A + one item in either B or C
Definite diagnosis: One item in A, one item in B and one item in C

Note: ERCP= Endoscopic retrograde cholangiopancreatography, PTCA =Percutaneous transhepatic cholangiography

A-2: Abnormal white blood cell counts, increase of serum C-reactive protein levels, and other changes indicating inflammation

B-2: Increased serum ALP, γGTP (GGT), AST and ALT levels.

Thresholds TG-13^‡
Category^‡	Clinical/ Lab feature	Test/Units	Value
A1	Fever	Body temp	>38° C
A2	Evidence of inflammatory response	WBC (x1000μ/L)	<4 or>10
A2	Evidence of inflammatory response	CRP (mg/dl)	≥1
B1	Jaundice	Total bilirubin (mg/dL)	≥ 2
B2	Abnormal liver function test	ALP (IU)	>1.5 x STD
		γGTP (IU)	>1.5 x STD
		AST (IU)	>1.5 x STD
		AST (IU)	>1.5 x STD

STD=upper limit of normal value, ALP= alkaline phosphatase, γGTP (GGT)= γ-glutamyltransferase, AST= aspartate aminotransferase, ALT= alanine aminotransferase

An algorithm showing course of management:

Signs of acute cholangitis

•Hospitalization
•IV fluids
•Broad spectrum antibiotics

Improvement after hospitalization and/or hydration
and/or broad spectrum antibiotics

Yes

No

Mild cholangitis

Organ dysfunction present?
•Hypotension
(which requires dobutamine or dopamine
@ 5μg/kg/min)
•Confusion
•PaO2:FiO2 ratio<300
•Serum creatinine>177 μmol/L

Elective ERCP and stone clearance

No

Yes

Moderate cholangitis

Severe cholangitis

ERCP within 24-48 hours
•Stone clearance if stable
•Stent if unstable

Urgent ERCP and stent

References

↑ Lee, John G. (2009). "Diagnosis and management of acute cholangitis". Nature Reviews Gastroenterology & Hepatology. 6 (9): 533–541. doi:10.1038/nrgastro.2009.126. ISSN 1759-5045.
↑ Kiriyama, Seiki; Takada, Tadahiro; Strasberg, Steven M.; Solomkin, Joseph S.; Mayumi, Toshihiko; Pitt, Henry A.; Gouma, Dirk J.; Garden, O. James; Büchler, Markus W.; Yokoe, Masamichi; Kimura, Yasutoshi; Tsuyuguchi, Toshio; Itoi, Takao; Yoshida, Masahiro; Miura, Fumihiko; Yamashita, Yuichi; Okamoto, Kohji; Gabata, Toshifumi; Hata, Jiro; Higuchi, Ryota; Windsor, John A.; Bornman, Philippus C.; Fan, Sheung-Tat; Singh, Harijt; de Santibanes, Eduardo; Gomi, Harumi; Kusachi, Shinya; Murata, Atsuhiko; Chen, Xiao-Ping; Jagannath, Palepu; Lee, Sung Gyu; Padbury, Robert; Chen, Miin-Fu; Dervenis, Christos; Chan, Angus C.W.; Supe, Avinash N.; Liau, Kui-Hin; Kim, Myung-Hwan; Kim, Sun-Whe (2013). "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)". Journal of Hepato-Biliary-Pancreatic Sciences. 20 (1): 24–34. doi:10.1007/s00534-012-0561-3. ISSN 1868-6974.

[Lee2009-1] Lee, John G. (2009). "Diagnosis and management of acute cholangitis". Nature Reviews Gastroenterology & Hepatology. 6 (9): 533–541. doi:10.1038/nrgastro.2009.126. ISSN 1759-5045.

[KiriyamaTakada2013-2] Kiriyama, Seiki; Takada, Tadahiro; Strasberg, Steven M.; Solomkin, Joseph S.; Mayumi, Toshihiko; Pitt, Henry A.; Gouma, Dirk J.; Garden, O. James; Büchler, Markus W.; Yokoe, Masamichi; Kimura, Yasutoshi; Tsuyuguchi, Toshio; Itoi, Takao; Yoshida, Masahiro; Miura, Fumihiko; Yamashita, Yuichi; Okamoto, Kohji; Gabata, Toshifumi; Hata, Jiro; Higuchi, Ryota; Windsor, John A.; Bornman, Philippus C.; Fan, Sheung-Tat; Singh, Harijt; de Santibanes, Eduardo; Gomi, Harumi; Kusachi, Shinya; Murata, Atsuhiko; Chen, Xiao-Ping; Jagannath, Palepu; Lee, Sung Gyu; Padbury, Robert; Chen, Miin-Fu; Dervenis, Christos; Chan, Angus C.W.; Supe, Avinash N.; Liau, Kui-Hin; Kim, Myung-Hwan; Kim, Sun-Whe (2013). "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)". Journal of Hepato-Biliary-Pancreatic Sciences. 20 (1): 24–34. doi:10.1007/s00534-012-0561-3. ISSN 1868-6974.

[1]

[2]

@@ Line 4: / Line 4: @@
 ==Diagnostic criteria==
+An algorithm  for diagnosis of cholangitis:<ref name="Lee2009">{{cite journal|last1=Lee|first1=John G.|title=Diagnosis and management of acute cholangitis|journal=Nature Reviews Gastroenterology & Hepatology|volume=6|issue=9|year=2009|pages=533–541|issn=1759-5045|doi=10.1038/nrgastro.2009.126}}</ref><ref name="KiriyamaTakada2013">{{cite journal|last1=Kiriyama|first1=Seiki|last2=Takada|first2=Tadahiro|last3=Strasberg|first3=Steven M.|last4=Solomkin|first4=Joseph S.|last5=Mayumi|first5=Toshihiko|last6=Pitt|first6=Henry A.|last7=Gouma|first7=Dirk J.|last8=Garden|first8=O. James|last9=Büchler|first9=Markus W.|last10=Yokoe|first10=Masamichi|last11=Kimura|first11=Yasutoshi|last12=Tsuyuguchi|first12=Toshio|last13=Itoi|first13=Takao|last14=Yoshida|first14=Masahiro|last15=Miura|first15=Fumihiko|last16=Yamashita|first16=Yuichi|last17=Okamoto|first17=Kohji|last18=Gabata|first18=Toshifumi|last19=Hata|first19=Jiro|last20=Higuchi|first20=Ryota|last21=Windsor|first21=John A.|last22=Bornman|first22=Philippus C.|last23=Fan|first23=Sheung-Tat|last24=Singh|first24=Harijt|last25=de Santibanes|first25=Eduardo|last26=Gomi|first26=Harumi|last27=Kusachi|first27=Shinya|last28=Murata|first28=Atsuhiko|last29=Chen|first29=Xiao-Ping|last30=Jagannath|first30=Palepu|last31=Lee|first31=Sung Gyu|last32=Padbury|first32=Robert|last33=Chen|first33=Miin-Fu|last34=Dervenis|first34=Christos|last35=Chan|first35=Angus C.W.|last36=Supe|first36=Avinash N.|last37=Liau|first37=Kui-Hin|last38=Kim|first38=Myung-Hwan|last39=Kim|first39=Sun-Whe|title=TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)|journal=Journal of Hepato-Biliary-Pancreatic Sciences|volume=20|issue=1|year=2013|pages=24–34|issn=18686974|doi=10.1007/s00534-012-0561-3}}</ref>
 {{familytree/start}}
 {{familytree | | | | | | | | | |A01| | | | | |A01= '''Diagnosis of <br>acute cholangitis'''}}
@@ Line 10: / Line 10: @@
 {{familytree | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
 {{familytree | | |!| | | | | | | |!| | | | | | |!| }}
-{{familytree |boxstyle=text-align: left| |B01| | | | | |B02| | | | |B03|B01='''Definitive diagnosis'''<br><br>Signs of infection and pus finding in bile during:<br>•[[ERCP]]<br>•[[PTCA]]<br>•Surgery|B02='''Charcot triad'''<br>•[[Fever]]<br>•[[Jaundice]]<br>•[[Abdominal pain]]<br><br>'''Reynold's pentad''' (includes 2 extra features)<br>•[[Sepsis]]<br>•[[Mental confusion]]|B03= '''Tokyo guidelines 2013(TG 13) '''<br><br>A.'''Systemic inflammation'''<br>A-1. [[Fever]] and/or shaking [[chills]]<br>A-2. Laboratory data: evidence of inflammatory response<br><br>B.'''Cholestasis'''<br>B-1. Jaundice<br>B-2. Laboratory data: abnormal liver function tests<br><br>C.'''Imaging'''<br>C-1. Biliary dilatation<br>C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)<br><br>Suspected diagnosis: One item in A + one item in either B or C<br>'''Definite diagnosis''': One item in A, one item in B and one item in C}}
+{{familytree |boxstyle=text-align: left| |B01| | | | | |B02| | | | |B03|B01='''Definitive diagnosis'''<br><br>Signs of infection and pus finding in bile during:<br>•[[ERCP]]<br>•[[PTCA]]<br>•Surgery|B02='''Charcot triad'''<br>•[[Fever]]<br>•[[Jaundice]]<br>•[[Abdominal pain]]<br><br>'''Reynold's pentad''' (includes 2 extra features)<br>•[[Sepsis]]<br>•[[Mental confusion]]|B03= '''Tokyo guidelines 2013(TG 13)<sup>‡</sup>  '''<br><br>A.'''Systemic inflammation'''<br>A-1. [[Fever]] and/or shaking [[chills]]<br>A-2. Laboratory data: evidence of inflammatory response<br><br>B.'''Cholestasis'''<br>B-1. Jaundice<br>B-2. Laboratory data: abnormal liver function tests<br><br>C.'''Imaging'''<br>C-1. Biliary dilatation<br>C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.)<br><br>Suspected diagnosis: One item in A + one item in either B or C<br>'''Definite diagnosis''': One item in A, one item in B and one item in C}}
 {{familytree/end}}
   Note: ERCP= [[Endoscopic retrograde cholangiopancreatography]], PTCA =[[Percutaneous transhepatic cholangiography]]<br>
-A-2: Abnormal white blood cell counts, increase of serum C-reactive protein levels, and other changes indicating inflammation<br>
+ A-2: Abnormal white blood cell counts, increase of serum [[C-reactive protein]] levels, and other changes indicating inflammation<br>
-B-2: Increased serum ALP, cGTP (GGT), AST and ALT levels.
+ B-2: Increased serum [[ALP]], γGTP ([[GGT]]), [[AST]] and [[ALT]] levels.
+{| class="wikitable"
+! colspan="4" |Thresholds TG-13<sup>‡</sup>
+|-
+!Category<sup>‡</sup>
+!Clinical/
+Lab feature
+!Test/Units
+!Value
+|-
+|A1
+|Fever
+|Body temp
+|>38° C
+|-
+| rowspan="2" |A2
+| rowspan="2" |Evidence of inflammatory response
+|WBC (x1000μ/L)
+|<4 or>10
+|-
+|CRP (mg/dl)
+|≥1
+|-
+|B1
+|Jaundice
+|Total bilirubin
+(mg/dL)
+|≥ 2
+|-
+| rowspan="4" |B2
+| rowspan="4" |Abnormal liver function test
+|ALP (IU)
+|>1.5 x STD
+|-
+|γGTP (IU)
+|>1.5 x STD
+|-
+|AST (IU)
+|>1.5 x STD
+|-
+|AST (IU)
+|>1.5 x STD
+|}
+ STD=upper limit of normal value, ALP= alkaline phosphatase, γGTP (GGT)= γ-glutamyltransferase, AST= aspartate aminotransferase, ALT= alanine aminotransferase
+*An algorithm showing course of management:
+{{familytree/start}}
+{{familytree | | | | | | | | | |A01| | | | | |A01= '''Signs of acute cholangitis'''}}
+{{familytree | | | | | | | | | | |!| | | | | | | | }}
+{{familytree | | | | | | | | | |B01| | | | | | | |B01=•Hospitalization<br>•IV fluids<br>•Broad spectrum antibiotics }}
+{{familytree | | | | | | | | | | |!| | | | | | | | }}
+{{familytree | | | | | | | | | |C01| | | | | | | |C01=Improvement after hospitalization and/or hydration<br> and/or broad spectrum antibiotics}}
+{{familytree | | | | | | | | | | |!| | | | | | | | }}
+{{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | }}
+{{familytree | | | | | |!| | | | | | | | | |!| | | }}
+{{familytree | | | | | D01 | | | | | | | | D02 | | |D01=Yes|D02=No}}
+{{familytree | | | | | |!| | | | | | | | | |!| | | }}
+{{familytree |boxstyle=text-align: left | | | | | E01 | | | | | | | | E02 | E01=Mild cholangitis| E02='''Organ dysfunction present?''' <br> •[[Hypotension]] <br>(which requires [[dobutamine]] or [[dopamine]]<br> @ 5μg/kg/min)<br> •[[Confusion]] <br> •PaO2:FiO2 ratio<300<br>•Serum [[creatinine]]>177 μmol/L}}
+{{familytree | | | | | |!| | | | | | | | | |!| | | }}
+{{familytree | | | | | F01 | | | | | | | | |!| |F01=Elective [[ERCP]] and stone clearance}}
+{{familytree | | | | | | | | | | | | | | | |!| | | }}
+{{familytree | | | | | | | | | |,|-|-|-|-|-|^|-|.}}
+{{familytree | | | | | | | | |G01| | | | | | G02 |G01= No|G02=Yes| }}
+{{familytree | | | | | | | | | |!| | | | | | | |!| | }}
+{{familytree | | | | | | | | |H01| | | | | |H02| H01=Moderate cholangitis|H02=Severe cholangitis }}
+{{familytree | | | | | | | | | |!| | | | | | | |!| | }}
+{{familytree |boxstyle=text-align: left | | | | | | | | |I01| | | | | |I02|I01=[[ERCP]] within 24-48 hours<br>•Stone clearance if stable<br>•Stent if unstable|I02= Urgent [[ERCP]] and stent }}
+{{familytree/end}}
 ==References==
 {{reflist|2}}

Cholangitis diagnostic criteria: Difference between revisions

Latest revision as of 16:01, 15 December 2017

Diagnostic criteria

References

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