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KP TSUI UNITED CHRISTIAN HOSPITAL The Tokyo Guidelines for Cholangitis.

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Presentation on theme: "KP TSUI UNITED CHRISTIAN HOSPITAL The Tokyo Guidelines for Cholangitis."— Presentation transcript:

1 KP TSUI UNITED CHRISTIAN HOSPITAL The Tokyo Guidelines for Cholangitis

2 Cholangitis Biliary infection associated with partial or complete obstruction of the biliary tree Diagnosis based on clinical findings, such as Charcot’s triad, with laboratory data and imaging findings

3 Charcot’s triad - Fever - Jaundice - Abdominal pain

4 Reynold’s Pentad - + Hypotension - + Mental obtundation

5 Lai EC, Tam PC, Paterson IA, Ng MM, Fan ST, Choi TK, et al. Emergency surgery for severe acute cholangitis. The high-risk patients. Ann Surg 1990;211:55–9.

6 There was no standard criteria for the diagnosis and severity assessment

7 Tokyo guidelines Based on a systematic review of literature and consensus of experts at the International Consensus Meeting in Tokyo 2006

8 TG07 A. Clinical contest and clinical manifestations 1.History of biliary disease 2.Fever and/or chills 3.Jaundice 4.Abdominal pain (RUQ or upper abdominal) B. Laboratory data5. Evidence of inflammatory response 6. Abnormal liver function tests C. Imaging findings7. Biliary dilatation, or evidence of an etiology (stricture, stone, stent etc) Suspected diagnosis2 or more items in A Definite diagnosis(1)Charcot’s triad (2+3+4) (2)Two or more items in A + both items in B and item C Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg (2007) 14:52–58

9 B-5: abnormal WBC, raised CRP and other changes indicating inflammation B-6: raised ALP, r-GTP (GGT), AST and ALT levels

10 Severity assessment criteria 2007 Mild (grade I): acute cholangitis which responds to the initial medical treatment

11 Moderate (grade II) acute cholangitis which does not respond to the initial medical treatment and is not accompanied by organ dysfunction

12 TG07 Severity assessment criteria Grade III (severe) - Associated with onset of dysfunction in at least one of the following organs/ systems 1. Cardiovascular dysfunctionHypotension requiring dopamine >=5ug/kg per min, or any dose of norepinephrine 2. Neurological dysfunctionDisturbance of consciousness 3. Respiratory dysfunctionPaO2/FiO2 ratio < Renal dysfunctionOiguria, serum creatinine > 2.0mg/dl 5. Hepatic dysfunctionPT-INR > Hematological dysfunctionPlatelet count < /mm3

13 Because of new information, the Tokyo Guidelines Revision Committee was organized to develop the update Tokyo guidelines (TG13)

14 Multiple tertiary centers in Japan From Jan 2007 and July patients with cholangitis

15 Revision of TG07 The diagnostic criteria was adjusted to achieve the highest sensitivity and specificity

16 TG07 A. Clinical contest and clinical manifestations 1.History of biliary disease 2.Fever and/or chills 3.Jaundice 4.Abdominal pain (RUQ or upper abdominal) B. Laboratory data5. Evidence of inflammatory response 6. Abnormal liver function tests C. Imaging findings7. Biliary dilatation, or evidence of an etiology (stricture, stone, stent etc) Suspected diagnosis2 or more items in A Definite diagnosis(1)Charcot’s triad (2+3+4) (2)Two or more items in A + both items in B and item C Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg (2007) 14:52–58

17 New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

18 TG13 diagnostic criteria A.Systemic inflammation A-1. Fever +/- 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 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 New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

19 A-2: abnormal WBC, raised CRP and other changes indicating inflammation B-2: raised ALP, r-GTP (GGT), AST and ALT levels

20 New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

21 With suspected diagnosis, early biliary drainage and source control of infection can be provided

22 Formulation of new severity assessment TG07 insufficient in separating Grade I and Grade II Need 24 hour observation period Definition of grade II ambiguous

23 New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines. J Hepatobiliary Pancreat Sci (2012) 19:548–556

24 TG13 Severity assessment criteria Grade III (severe) - Associated with onset of dysfunction in at least one of the following organs/ systems 1. Cardiovascular dysfunctionHypotension requiring dopamine >=5ug/kg per min, or any dose of norepinephrine 2. Neurological dysfunctionDisturbance of consciousness 3. Respiratory dysfunctionPaO2/FiO2 ratio < Renal dysfunctionOiguria, serum creatinine > 2.0mg/dl 5. Hepatic dysfunctionPT-INR > Hematological dysfunctionPlatelet count < /mm3

25 Grade II ( moderate ) - Any 2 of the following 1. Abnormal WBC count (>12000/mm3, < 4000/mm3) 2. High fever (>=39C) 3. Age (>=75 years) 4. Hyperbilirubinemia (total bilirubin >=5 mg/ dl) 5. Hypoalbuminemia (< STD x 0.7)

26 Grade I (mild) -Does not meet criteria for Grade II or Grade III at initial diagnosis

27 TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci (2013) 20:47–54

28 TG13 management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci (2013) 20:55–59

29 Tokyo guidelines Minimal recognition outside Japan Several retrospective studies have validated its diagnostic value Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

30 Tokyo guidelines 2007 Based on Japanese studies - Sensitivity: % - Charcot’s triad < 40% Accuracy of the Tokyo Guidelines for the diagnosis of acute cholangitis and cholecystitis taking into consideration the clinical practice pattern in Japan. J Hepatobiliary Pancreat Sci 2011;18:

31 Tokyo guidelines 2007 Classification into mild or moderate grade using the Tokyo Guidelines is difficult when early biliary drainage is routinely performed. Journal of Hepato-Biliary-Pancreatic Sci, July 2012, Volume 19, Issue 4, pp Verification of Tokyo Guidelines for diagnosis and management of acute cholangitis

32 “Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital” Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

33 First study to verify the application of TG07 for diagnosis and treatment of cholangitis in Chinese patients Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

34 At Chinese PLA General Hospital, Beijing 120 patients 82 benign; 38 malignant Retrospective from ERCP database

35 Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

36 Definite diagnosis - 68 (82.9%) benign patients - 36 (94.7%) malignant (86.7%) overall Charcot’s triad - 61 (50.8%) overall Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

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38 No significant difference in clinical outcome was observed in patients of different severity grades Conclusion: The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital. Hepatobiliary Pancreat Dis Int, Vol 12, No 4, August 1, 2013.

39 Compliance acute cholangitis patients from the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system. Grade III: 7.6 ± 2.1 Grade II:6.5 ± 3.0 Grade I:2.9 ± 0.9, p < (score 0 = 0% to score 10 = 100%) Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system. Journal of Hepato-Biliary-Pancreatic Sciences, January 2011, Volume 18, Issue 1, pp 53-59

40 Improved prognosis of in-hospital mortality with odds ratio of among patients with high compliance with the TG07

41 Take home message The Tokyo guidelines are more sensitive than Charcot’s triad for diagnosis of cholangitis TG13 produces a new standard for diagnosis, severity grading and management of acute cholangitis Awaiting further validation on TG13


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