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Chapter 67: Perspective on Biliary Chapters

Steven M. Strasberg

INTRODUCTION

This is a perspective on biliary diseases to complement the excellent chapters on biliary tract disease in this text. It focuses on areas in my experience that I believe deserve emphasis.

TOKYO GUIDELINES FOR ACUTE CHOLECYSTITIS AND ACUTE CHOLANGITIS

The Tokyo Guidelines (TG) provide evidence based criteria for the diagnosis and severity grading of acute cholecystitis and acute cholangitis. First published in 2007, there have been two revisions, the latest just published in 2018 (TG18). The guidelines are available in an app for smartphones, and the app is very useful in the ER and on the ward. Furthermore, standardization of criteria for diagnosis and severity grading provide a stable platform for performance of comparative outcome studies.1,2 Tables 67-1, 67-2, 67-3, 67-4 are Tokyo guidelines 2018 diagnostic criteria and severity grading for acute cholangitis and acute cholecystitis respectively.

TABLE 67-1TOKYO GUIDELINES 2018 DIAGNOSTIC CRITERIA FOR ACUTE CHOLECYSTITIS
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TABLE 67-1 TOKYO GUIDELINES 2018 DIAGNOSTIC CRITERIA FOR ACUTE CHOLECYSTITIS

A. Local signs of inflammation.

(1) Murphy’s sign, (2) RUQ mass/pain/tenderness

B. Systemic signs of inflammation, etc.

(1) fever, (2) elevated CRP, (3) elevated WBC count

C. Imaging findings

Imaging findings characteristic of acute cholecystitis

Suspected diagnosis: One item in A + one item in B

Definite diagnosis: One item in A + one item in B + C

Reproduced with permission from Yokoe M, Takada T, Strasberg SM, et al: New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines, J Hepatobiliary Pancreat Sci. 2012 Sep;19(5):578-585.

TABLE 67-2TOKYO GUIDELINES 2018 SEVERITY GRADING FOR ACUTE CHOLECYSTITIS
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TABLE 67-2 TOKYO GUIDELINES 2018 SEVERITY GRADING FOR ACUTE CHOLECYSTITIS

Grade III (Severe) acute cholecystitis

“Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems

  1. Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≧ 5µg/kg per min, or any dose of Norepinephrine)

  2. Neurological dysfunction: decreased level of consciousness

  3. Respiratory dysfunction PaO2/FiO2 ratio < 300

  4. Renal dysfunction Oliguria, creatinine > 2.0 mg/dl

  5. Hepatic dysfunction PT-INR > 1.5

  6. Hematological dysfunction Platelet count < 100,000/mm3

Grade II (moderate) acute cholecystitis

“Grade II” acute cholecystitis is associated with any one of the following conditions.

  1. Elevated WBC count (> 18,000/mm3)

  2. Palpable tender mass in the right upper abdominal quadrant

  3. Duration of complaints > 72 hr

  4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade I (mild) acute cholecystitis

“Grade I” acute cholecystitis that does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure.

Modified with permission from Yokoe M, Takada T, Strasberg SM, et al: New diagnostic criteria ...

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