Maryam Razavi

maryam.razavi@cambio.se

@CambioCDS

To objectively guide diagnosis and management of patients with acute cholangitis in terms of timing and need for biliary drainage and supportive care.

Use in patients with suspected acute cholangitis (i.e., fever, jaundice, right upper quadrant pain, altered mental status, and/or hemodynamic instability). Formula: Patient must have a suspected diagnosis (≥1 item in A + ≥1 item in B or C) or definite diagnosis (≥1 item in A, B, and C) to meet entry criteria for severity grading, see table below: Variables (assigned points: No=0, Yes=1) - Part A: Systemic Inflammation 1. Fever and/or shaking chills (>38°C/100.4°F): No=0, Yes=1 2. Laboratory data: evidence of inflammatory response (WBC <4 or >10 x1,000/μL and/or CRP ≥1 mg/dL): No=0, Yes=1 - Part B: Cholestasis 1. Jaundice (Total bilirubin ≥2 mg/dL): No=0, Yes=1 2. Laboratory data: abnormal liver enzymes (ALP, γGTP, AST, ALT levels >1.5 x STD): No=0, Yes=1 -Part C: Imaging 1. Biliary dilatation: No=0, Yes=1 2. Evidence of the etiology on imaging: No=0, Yes=1 Severity grading: - Grade III (dysfunction in ≥1 of the following): -- Cardiovascular dysfunction: hypotension requiring dopamine ≥5 μg/kg per min or any dose of norepinephrine -- Neurological dysfunction: disturbance of consciousness -- Respiratory dysfunction: PaO₂/FiO₂ ratio <300 -- Renal dysfunction: oliguria or creatinine >2.0 mg/dL -- Hepatic dysfunction: PT‐INR >1.5 -- Hematological dysfunction: platelet count <100,000/mm³ - Grade II (≥2 of the following conditions): -- Abnormal WBC count (>12,000/mm³ or <4,000/mm³) -- High fever (≥39°C/102.2°F) -- Age ≥75 years -- Hyperbilirubinemia (total bilirubin ≥5 mg/dL) -- Hypoalbuminemia (<0.7 x upper limit of normal) - Grade I -- Does not meet the criteria of Grade III or Grade II acute cholangitis at initial diagnosis Interpretations: Grade I =Mild Acute cholangitis severity= Recommendations: Antibiotics and general supportive care; consider biliary drainage if no response to initial treatment Grade II =Moderate Acute cholangitis severity= Recommendations: Antibiotics and general supportive care; early endoscopic or percutaneous transhepatic biliary drainage is indicated Grade III =Severe Acute cholangitis severity= Recommendations: Initial treatment with antibiotics, urgent biliary drainage, appropriate respiratory/circulatory management

1. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17-30.

OBSERVATION.tg18_cholangitis.v0