{
  "schemaVersion": 2,
  "eyebrow": "Gastroenterology",
  "title": "Acute Cholangitis Biliary Drainage",
  "summary": "Biliary drainage timing is determined by physiologic severity and response to initial resuscitation. Perform urgent decompression for organ dysfunction, early drainage for moderate disease, and reserve antibiotics-alone management for improving mild cholangitis without persistent obstruction.",
  "seoDescription": "Physician guidance on ERCP and alternative biliary drainage timing in acute cholangitis by Tokyo severity grade, response to treatment, and obstruction.",
  "clinicalQuestion": "When should patients with acute cholangitis undergo biliary drainage, and which drainage approach should be selected?",
  "specialty": "Gastroenterology",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "acute cholangitis",
    "biliary drainage timing",
    "urgent ERCP",
    "Tokyo Guidelines",
    "biliary decompression",
    "percutaneous transhepatic biliary drainage"
  ],
  "keyTakeaways": [
    "Assess severity immediately after starting initial medical treatment; Grade III cholangitis requires organ support and biliary drainage as soon as the patient is stabilized sufficiently for intervention. [10][23]",
    "Perform early endoscopic or percutaneous transhepatic biliary drainage for Grade II cholangitis rather than waiting for failure of conservative therapy. [10][23]",
    "For Grade I cholangitis, antibiotics and initial treatment are usually sufficient; proceed to drainage when the patient does not respond or when persistent biliary obstruction requires source control. [10][13][23]",
    "Use ERCP-based drainage when feasible because endoscopic drainage has lower morbidity and shorter hospitalization than percutaneous approaches; use percutaneous drainage when endoscopic drainage is not feasible or unsuccessful. [19][22]",
    "In gallstone pancreatitis without cholangitis, early ERCP within 72 hours has not shown benefit; do not extrapolate the urgent-drainage indication from cholangitis to uncomplicated biliary pancreatitis. [4]"
  ],
  "sections": [
    {
      "id": "triage-and-severity",
      "eyebrow": "Immediate triage",
      "heading": "Determine whether biliary drainage is emergent, early, or conditional",
      "intro": "Severity and initial response determine drainage urgency.",
      "paragraphs": [
        "Treat suspected acute cholangitis as infection in a potentially obstructed biliary system: begin initial medical treatment immediately, assess cholangitis severity, and evaluate global physiologic status in parallel. Obstruction raises intraductal pressure and can promote cholangiovenous or cholangiolymphatic reflux with systemic infection; decompression is therefore the source-control intervention when obstruction persists. [10][13]",
        "Classify severity using the Tokyo Grade I, II, and III framework. Grade III disease is defined by organ dysfunction and requires respiratory and circulatory management plus biliary drainage as soon as possible after initial stabilization. Grade II disease has no organ dysfunction but warrants early endoscopic or percutaneous transhepatic biliary drainage. Grade I disease can initially be managed medically, with drainage triggered by failure to improve. [20][23]",
        "Do not use the absence of Charcot triad to defer evaluation or source control. Diagnosis is supported by the combination of systemic inflammation, cholestasis, and biliary abnormalities on imaging; recent biliary intervention or an indwelling stent can complicate diagnostic performance of clinical criteria. [8][13][14]"
      ],
      "bullets": [
        "Grade III: provide organ support and arrange biliary decompression as soon as possible after initial stabilization. [23]",
        "Grade II: arrange early ERCP drainage or percutaneous transhepatic biliary drainage. [10][23]",
        "Grade I: reassess after initial treatment; drain if clinical or laboratory response is inadequate or if persistent obstruction requires intervention. [10][22][23]"
      ],
      "subsections": [],
      "table": {
        "caption": "Drainage urgency should follow Tokyo severity grade and clinical response. [10][20][23]",
        "columns": [
          "Severity branch",
          "Defining management discriminator",
          "Drainage action"
        ],
        "rows": [
          [
            "Grade III (severe)",
            "Organ dysfunction; requires respiratory and/or circulatory management. [20][23]",
            "Perform biliary drainage as soon as possible after initial stabilization. [23]"
          ],
          [
            "Grade II (moderate)",
            "No organ dysfunction but illness requiring early source control. [20][23]",
            "Perform early endoscopic or percutaneous transhepatic biliary drainage. [10][23]"
          ],
          [
            "Grade I (mild)",
            "Improves with initial treatment and has no severe or moderate features. [10][20]",
            "Initial treatment including antibiotics is usually sufficient; consider drainage if there is inadequate response. [10][23]"
          ]
        ]
      }
    },
    {
      "id": "initial-workup",
      "eyebrow": "Before source control",
      "heading": "Obtain cultures and define the obstructing lesion without delaying necessary drainage",
      "intro": "Testing should establish obstruction, severity, and procedural route.",
      "paragraphs": [
        "Obtain blood cultures before antibiotics when this can be done without delaying resuscitation or biliary drainage. Acute cholangitis is frequently complicated by bacteremia, and biliary obstruction from stones or malignant strictures can promote bacteremia and life-threatening organ failure. [15]",
        "Use liver biochemical testing, inflammatory markers, and biliary imaging to support the diagnosis and identify the target for drainage. Inflammatory laboratory abnormalities plus cholestasis and biliary manifestations on imaging support acute cholangitis; imaging should identify ductal dilation, choledocholithiasis, a stricture, or a malignant obstruction that changes the likely durable drainage strategy. [8][13][20]",
        "Separate cholangitis from acute gallstone pancreatitis because this distinction changes the ERCP threshold. Urgent ERCP is indicated when cholangitis is suspected, whereas randomized trials found no benefit from early ERCP within 72 hours in acute biliary pancreatitis without cholangitis. ERCP-related acute pancreatitis risk is reported at 5% to 20%. [4][6]"
      ],
      "bullets": [
        "Send blood cultures before antimicrobial therapy when feasible; do not postpone drainage in an unstable patient for culture collection. [15][23]",
        "Use imaging evidence of a stone, stricture, malignancy, ductal dilation, or other biliary abnormality to determine whether decompression is needed and to plan the route. [8][13]",
        "If the presentation is pancreatitis without cholangitis, avoid reflex emergency ERCP solely to remove a presumed passed stone. [4]"
      ],
      "subsections": [],
      "table": {
        "caption": "Findings that alter the drainage decision in suspected acute cholangitis. [8][13][14][15]",
        "columns": [
          "Finding",
          "Interpretation",
          "Next action"
        ],
        "rows": [
          [
            "Inflammation plus cholestasis plus biliary imaging abnormality",
            "Supports acute cholangitis under Tokyo diagnostic criteria. [8]",
            "Grade severity and determine need for endoscopic or percutaneous drainage. [10][23]"
          ],
          [
            "Ductal stone or persistent biliary obstruction",
            "Obstruction is a source-control target; decompression is central when obstruction is present. [13]",
            "Plan ERCP drainage when feasible; treat the stone definitively after or during drainage when clinically appropriate. [23]"
          ],
          [
            "Recent biliary intervention or indwelling stent",
            "Existing clinical criteria have reduced diagnostic accuracy in patients with preexisting biliary stents. [13]",
            "Integrate imaging, laboratory trajectory, cultures, and physiologic severity rather than relying on a single diagnostic rule. [13][14]"
          ],
          [
            "Gallstone pancreatitis without cholangitis",
            "Early ERCP has not shown benefit in randomized trials when cholangitis is absent. [4]",
            "Use conservative management rather than indiscriminate emergency ERCP. [4]"
          ]
        ]
      }
    },
    {
      "id": "timing-by-clinical-course",
      "eyebrow": "Timing",
      "heading": "Use response to initial treatment only for mild disease",
      "intro": "Failure to improve converts observation into a drainage decision.",
      "paragraphs": [
        "For Grade I cholangitis, begin immediate medical therapy and reassess the clinical and laboratory trajectory. Most patients with mild disease do not require biliary drainage initially, but drainage should be considered when initial treatment does not produce improvement. This approach is most defensible when there is no persistent obstructing lesion requiring definitive source control. [10][13][23]",
        "For Grade II disease, do not wait for prolonged antibiotic response before arranging early drainage. In the TG13 multicenter analysis, 46% of Grade II cases required urgent or early biliary drainage, supporting the separation of moderate disease from Grade I observation pathways. [16][18]",
        "For Grade III disease, do not delay decompression until complete normalization of hemodynamics or laboratory tests. The operational sequence is immediate resuscitation and organ support followed by drainage as soon as possible once the patient’s general condition has been improved sufficiently for the procedure. The exact optimal clock time for Grade II and III disease remains debated across guidelines and clinical studies, but the direction of care is early source control rather than deferred intervention. [17][23]"
      ],
      "bullets": [
        "Escalate Grade I disease to biliary drainage for persistent clinical or laboratory nonresponse after initial treatment. [10][22][23]",
        "Treat Grade II cholangitis as an early-drainage condition, even without organ dysfunction. [10][23]",
        "Treat Grade III cholangitis as a resuscitation-plus-urgent-drainage condition; ICU-level organ support may be required. [20][23]"
      ],
      "subsections": [
        {
          "heading": "When a stone is the obstructing lesion",
          "paragraphs": [
            "After stabilization, endoscopic sphincterotomy and choledocholithotomy may be performed with biliary drainage when clinically appropriate. In patients with concomitant gallbladder stones, cholecystectomy is recommended after acute cholangitis has resolved unless operative risk is poor or the patient declines surgery. [22][23]"
          ],
          "bullets": []
        }
      ],
      "table": {
        "caption": "Practical timing framework for biliary drainage. [10][17][22][23]",
        "columns": [
          "Clinical course",
          "Do not do",
          "Proceed with"
        ],
        "rows": [
          [
            "Grade I with objective improvement on initial treatment",
            "Do not mandate immediate drainage solely because cholangitis is diagnosed. [10][23]",
            "Continue medical treatment and monitor for nonresponse or evidence of persistent obstruction. [10][13]"
          ],
          [
            "Grade I without improvement",
            "Do not continue conservative treatment indefinitely. [22][23]",
            "Arrange biliary drainage as source control. [10][22]"
          ],
          [
            "Grade II",
            "Do not defer drainage for a prolonged trial of antibiotics alone. [10][23]",
            "Perform early endoscopic or percutaneous transhepatic drainage. [10][23]"
          ],
          [
            "Grade III",
            "Do not await full physiologic normalization before planning source control. [23]",
            "Provide organ support and perform drainage as soon as possible after initial stabilization. [20][23]"
          ]
        ]
      }
    },
    {
      "id": "selecting-drainage-route",
      "eyebrow": "Procedure selection",
      "heading": "Choose ERCP first when feasible; use percutaneous drainage when ERCP cannot provide source control",
      "intro": "The goal is effective biliary decompression with the least invasive successful route.",
      "paragraphs": [
        "Use endoscopic drainage when anatomy and local expertise permit. Endoscopic drainage is associated with lower morbidity and shorter hospitalization than percutaneous transhepatic drainage and is therefore the preferred route when applicable. Either endoscopic nasobiliary drainage or placement of a biliary tube stent can be used; reported success, effectiveness, and morbidity are not significantly different between these methods. [22]",
        "Use percutaneous transhepatic biliary drainage when endoscopic drainage is contraindicated, unavailable, or unsuccessful. In a reported series of 56 patients, clinical improvement followed percutaneous drainage in 82.1%, with fever resolution within 18 to 24 hours; another 42-patient report described 100% technical success, 7% morbidity, and 5% mortality. These observational outcomes support PTBD as a rescue or alternative decompression route rather than a reason to delay source control when ERCP is not feasible. [19]",
        "Reserve open surgical drainage for patients in whom endoscopic and percutaneous approaches are contraindicated or unsuccessful. The drainage procedure should first accomplish decompression; stone extraction, sphincterotomy, and later cholecystectomy should be individualized to physiologic stability, stone burden, and operative risk. [22][23]"
      ],
      "bullets": [
        "ERCP drainage: preferred when feasible because of lower morbidity and shorter hospitalization relative to percutaneous drainage. [22]",
        "Endoscopic nasobiliary drainage versus tube stent: either is reasonable for decompression; no significant difference in reported success, effectiveness, or morbidity. [22]",
        "PTBD: use after failed or infeasible endoscopic drainage. [19][22]",
        "Open drainage: reserve for failure or contraindication of both endoscopic and percutaneous approaches. [22]"
      ],
      "subsections": [],
      "table": {
        "caption": "Biliary drainage route selection in acute cholangitis. [19][22][23]",
        "columns": [
          "Route",
          "Best use",
          "Key tradeoff"
        ],
        "rows": [
          [
            "ERCP-based drainage",
            "First-line decompression when endoscopic access is feasible. [22]",
            "Lower morbidity and shorter hospitalization than percutaneous drainage; procedural adverse events remain relevant. [6][22]"
          ],
          [
            "Endoscopic nasobiliary drain or biliary tube stent",
            "Endoscopic decompression options during ERCP. [22]",
            "No significant reported difference in success, effectiveness, or morbidity. [22]"
          ],
          [
            "Percutaneous transhepatic biliary drainage",
            "Endoscopic drainage contraindicated, unavailable, or unsuccessful. [19][22]",
            "Provides an alternative source-control route but is generally not the preferred initial route when ERCP is feasible. [22]"
          ],
          [
            "Open surgical drainage",
            "Endoscopic and percutaneous methods cannot be performed or have failed. [22]",
            "Most invasive option; reserve for exceptional cases. [22]"
          ]
        ]
      }
    },
    {
      "id": "post-drainage-actions",
      "eyebrow": "After decompression",
      "heading": "Confirm clinical response and complete etiology-directed treatment",
      "intro": "Drainage resolves obstruction; definitive therapy addresses recurrence.",
      "paragraphs": [
        "After drainage, follow fever, hemodynamics, organ-support requirements, leukocyte count, bilirubin, aminotransferases, creatinine, and inflammatory markers to verify physiologic and cholestatic improvement. In severe cholangitis, serial SOFA and APACHE II scores, lactate, bilirubin, renal function, and inflammatory biomarkers have been used to assess response after endoscopic intervention. [3]",
        "For choledocholithiasis, complete stone-directed treatment after or in conjunction with drainage when the patient’s condition permits. TG18 notes that endoscopic sphincterotomy and subsequent choledocholithotomy may be performed with drainage; after resolution of cholangitis, offer cholecystectomy to patients with gallbladder stones unless operative risk is prohibitive or the patient declines. [22][23]",
        "If clinical deterioration or persistent cholestasis continues after an apparently successful procedure, reassess for incomplete drainage, retained stones, stricture, malignant obstruction, or another source of sepsis and pursue repeat endoscopic or alternative percutaneous drainage rather than assuming antibiotics alone will overcome inadequate source control. [13][19][22]"
      ],
      "bullets": [
        "Monitor physiologic recovery and cholestatic laboratory trends after decompression. [3]",
        "For stone-related cholangitis, plan definitive duct clearance when clinically appropriate. [23]",
        "Offer interval cholecystectomy after recovery when gallbladder stones are present and operative risk is acceptable. [22]"
      ],
      "subsections": [],
      "table": {
        "caption": "Post-drainage reassessment links response to the next intervention. [3][13][22][23]",
        "columns": [
          "Post-procedure finding",
          "Interpretation",
          "Next step"
        ],
        "rows": [
          [
            "Improving hemodynamics, fever, cholestasis, and inflammatory markers",
            "Consistent with effective source control and recovery. [3]",
            "Complete etiology-directed treatment, including stone clearance when indicated. [23]"
          ],
          [
            "Persistent instability or cholestasis",
            "Consider incomplete drainage or ongoing obstruction. [13]",
            "Reassess the drainage result and pursue repeat endoscopic or percutaneous decompression as appropriate. [19][22]"
          ],
          [
            "Gallbladder stones after resolved cholangitis",
            "Risk of recurrent gallstone disease remains. [22]",
            "Offer cholecystectomy unless poor operative risk or patient preference precludes surgery. [22]"
          ]
        ]
      }
    }
  ],
  "faq": [],
  "references": [
    {
      "number": 1,
      "title": "Gastrointestinal Endoscopy - The New England Journal of Medicine",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJM199110243251705",
      "authors": "www.nejm.org",
      "host": "www.nejm.org"
    },
    {
      "number": 2,
      "title": "Early versus delayed laparoscopic common bile duct exploration for common bile duct stone-related nonsevere acute cholangitis | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/srep11748",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 3,
      "title": "Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-69943-x",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 4,
      "title": "Increased ERCP-related adverse event from premature urgent ...",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-64644-x",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 5,
      "title": "Risk prediction of cholangitis after stent implantation based on machine learning | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-64734-w",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 6,
      "title": "Acute Pancreatitis | Annals of Internal Medicine - ACP Journals",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-153-9-201011020-01005",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 7,
      "title": "Piperacillin To Prevent Cholangitis after Endoscopic Retrograde ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-125-6-199609150-00002",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 8,
      "title": "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos) - Kiriyama - 2013 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1007/s00534-012-0561-3",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 9,
      "title": "TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis - Takada - 2013 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1007/s00534-012-0566-y",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 10,
      "title": "Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis - Miura - 2018 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1002/jhbp.509",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 11,
      "title": "Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines - Sekimoto - 2007 - Journal of Hepato-Biliary-Pancreatic Surgery - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1007/s00534-006-1151-z",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 12,
      "title": "Impact of frailty on outcomes and biliary drainage strategies in acute cholangitis: A retrospective cohort analysis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S2210740125000488",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 13,
      "title": "Prospective Assessment of Clinical Criteria for Diagnosis and Severity of Acute Cholangitis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S2590030723000156",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 14,
      "title": "Toward an evidence-based approach for cholangitis diagnosis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0016510721013146",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 15,
      "title": "Blood cultures should be collected for acute cholangitis regardless of severity",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1341321X21002737",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 16,
      "title": "New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC3429782",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov"
    },
    {
      "number": 17,
      "title": "Timing of biliary decompression for acute cholangitis - PMC",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9932428",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov"
    },
    {
      "number": 18,
      "title": "New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines - PMC",
      "detail": "www.ncbi.nlm.nih.gov",
      "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429782",
      "authors": "www.ncbi.nlm.nih.gov",
      "host": "www.ncbi.nlm.nih.gov"
    },
    {
      "number": 19,
      "title": "Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2799047",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov"
    },
    {
      "number": 20,
      "title": "Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines - PMC",
      "detail": "www.ncbi.nlm.nih.gov",
      "url": "http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784515",
      "authors": "www.ncbi.nlm.nih.gov",
      "host": "www.ncbi.nlm.nih.gov"
    },
    {
      "number": 21,
      "title": "Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2784515",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov"
    },
    {
      "number": 22,
      "title": "Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. - Abstract",
      "detail": "pubmed.ncbi.nlm.nih.gov",
      "url": "https://pubmed.ncbi.nlm.nih.gov/17252299",
      "authors": "pubmed.ncbi.nlm.nih.gov",
      "host": "pubmed.ncbi.nlm.nih.gov"
    },
    {
      "number": 23,
      "title": "Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. - Abstract",
      "detail": "pubmed.ncbi.nlm.nih.gov",
      "url": "https://pubmed.ncbi.nlm.nih.gov/28941329",
      "authors": "pubmed.ncbi.nlm.nih.gov",
      "host": "pubmed.ncbi.nlm.nih.gov"
    },
    {
      "number": 24,
      "title": "Study Details | NCT02107560 | Results of Bile and Blood Culture in Patients With Acute Cholangitis | ClinicalTrials.gov",
      "detail": "clinicaltrials.gov",
      "url": "https://clinicaltrials.gov/study/NCT02107560",
      "authors": "clinicaltrials.gov",
      "host": "clinicaltrials.gov"
    }
  ],
  "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.",
  "citations": [
    {
      "number": 1,
      "title": "Gastrointestinal Endoscopy - The New England Journal of Medicine",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJM199110243251705",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1989; 1:1307–9. Go to Citation. Crossref · PubMed · Web of Science · Google",
      "score": 0.43482184
    },
    {
      "number": 2,
      "title": "Early versus delayed laparoscopic common bile duct exploration for common bile duct stone-related nonsevere acute cholangitis | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/srep11748",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "Acute cholangitis is one of the most serious complications of CBD stones. Therefore, safe and effective therapeutic approaches are urgently needed. Approximately 80% of patients with acute cholangitis respond to broad spectrum antibiotics, whereas the rest requires early biliary drainage, including ",
      "score": 0.6760432
    },
    {
      "number": 3,
      "title": "Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-69943-x",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "Figure 1\n\nComparison of disease severities and laboratory findings prior and post endoscopic intervention. Results of disease severities and laboratory findings at Day 0, 1, 3 and 7 were collated and compared. (A) APACHE II and SOFA scores; (B) leucocyte counts; (C) serum arterial lactate; (D) serum",
      "score": 0.5585443
    },
    {
      "number": 4,
      "title": "Increased ERCP-related adverse event from premature urgent ...",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-64644-x",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "Article \nPubMed \nGoogle Scholar\n\nPécsi, D. et al. ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis—Analysis of the Hungarian ERCP registry data. Pancreatology 21, 59–63 (2021).\n\nArticle \nPubMed \nGoogle Scholar\n\nCanena, J. et al. Efficacy and safety of primary",
      "score": 0.5335682
    },
    {
      "number": 5,
      "title": "Risk prediction of cholangitis after stent implantation based on machine learning | Scientific Reports",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41598-024-64734-w",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "(2020).\"),5, 32–47. \n                  \n                  \n                 (2017).\"). If not treated in time, it was easy to cause systemic inflammatory response syndrome (SIRS), septic shock and even death, and the case fatality rate often exceeds 10%, even up to 27%6, 361–375. \n                  ",
      "score": 0.5037359
    },
    {
      "number": 6,
      "title": "Acute Pancreatitis | Annals of Internal Medicine - ACP Journals",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-153-9-201011020-01005",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "The risk for acute pancreatitis related to ERCP ranges from 5% to 20%, Urgent ERCP is indicated if cholangitis is suspected. studies have found",
      "score": 0.34112197
    },
    {
      "number": 7,
      "title": "Piperacillin To Prevent Cholangitis after Endoscopic Retrograde ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-125-6-199609150-00002",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "Many of these patients were considered to be at high risk for cholangitis after ERCP because of insufficient drainage of the biliary tract. It",
      "score": 0.26977462
    },
    {
      "number": 8,
      "title": "TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos) - Kiriyama - 2013 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1007/s00534-012-0561-3",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. The diagnostic criteria of a",
      "score": 0.81770587
    },
    {
      "number": 9,
      "title": "TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis - Takada - 2013 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1007/s00534-012-0566-y",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "# TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the *Journal of Hepato-Biliary-Pancreatic Surgery*. To be specific, discussion took place",
      "score": 0.8047902
    },
    {
      "number": 10,
      "title": "Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis - Miura - 2018 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1002/jhbp.509",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "# Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cho",
      "score": 0.7950386
    },
    {
      "number": 11,
      "title": "Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines - Sekimoto - 2007 - Journal of Hepato-Biliary-Pancreatic Surgery - Wiley Online Library",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1007/s00534-006-1151-z",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "# Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines. The Tokyo Guidelines formulate clinical guidance for healthcare providers regarding the diagnosis, severity assessment, and treatment of acute cholangitis and acute cholecystitis. ",
      "score": 0.7923522
    },
    {
      "number": 12,
      "title": "Impact of frailty on outcomes and biliary drainage strategies in acute cholangitis: A retrospective cohort analysis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S2210740125000488",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "### J Hepatobiliary Pancreat Surg\n\n### Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis\n\n### J Hepatobiliary Pancreat Sci\n\n### Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an ",
      "score": 0.7192461
    },
    {
      "number": 13,
      "title": "Prospective Assessment of Clinical Criteria for Diagnosis and Severity of Acute Cholangitis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S2590030723000156",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "We assessed the accuracy of 2 clinical criteria, Tokyo and BILE criteria, for the diagnosis and severity of acute cholangitis. We identified all patients from 2020-2021 seen at our institution with suspected cholangitis, defined as having abdominal pain or fever, and abnormal liver enzymes or biliar",
      "score": 0.7668008
    },
    {
      "number": 14,
      "title": "Toward an evidence-based approach for cholangitis diagnosis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0016510721013146",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "# Original article Clinical endoscopy Toward an evidence-based approach for cholangitis diagnosis. Although ERCP is an effective treatment for cholangitis, it should be reserved for those patients with a high probability of the diagnosis, given the morbidity associated with the procedure. A comprehe",
      "score": 0.73505294
    },
    {
      "number": 15,
      "title": "Blood cultures should be collected for acute cholangitis regardless of severity",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1341321X21002737",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Acute cholangitis is frequently complicated with bacteremia . Increased biliary pressure from obstruction of the bile duct by gallstones or malignant strictures induces bacterial infections and bacteremia . Bacteremia in acute cholangitis is known to be associated with mortality and life-threatening",
      "score": 0.67243975
    },
    {
      "number": 16,
      "title": "New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC3429782",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "We performed a multicenter analysis using the TG13 severity assessment criteria for acute cholangitis in real clinical settings. Of the 623 cases of acute cholangitis where severity grading was retrospectively made clear, there were 72 Grade III cases (11.6%), 216 Grade II cases (34.7%) and 335 Grad",
      "score": 0.8430832
    },
    {
      "number": 17,
      "title": "Timing of biliary decompression for acute cholangitis - PMC",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9932428",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "The 2018 revised Tokyo guideline (TG18) currently serves as the most influential guideline for assessing AC severity. It delineates three grades of assessment of AC severity and indicates that the impact of the BD implementation time on the therapeutic benefit is significantly correlated with AC sev",
      "score": 0.8390101
    },
    {
      "number": 18,
      "title": "New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines - PMC",
      "detail": "www.ncbi.nlm.nih.gov",
      "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429782",
      "authors": "www.ncbi.nlm.nih.gov",
      "host": "www.ncbi.nlm.nih.gov",
      "snippet": "We performed a multicenter analysis using the TG13 severity assessment criteria for acute cholangitis in real clinical settings. Of the 623 cases of acute cholangitis where severity grading was retrospectively made clear, there were 72 Grade III cases (11.6 %), 216 Grade II cases (34.7 %) and 335 Gr",
      "score": 0.8306082
    },
    {
      "number": 19,
      "title": "Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2799047",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "This is a simple question about “_The timing of biliary drainage for severe acute cholangitis_.” The options are: as soon as possible, or within 24 h, or following conservative treatment unless the patient has worsened. The results are very similar for the Japanese and overseas. Okay, we reached a c",
      "score": 0.826278
    },
    {
      "number": 20,
      "title": "Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines - PMC",
      "detail": "www.ncbi.nlm.nih.gov",
      "url": "http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784515",
      "authors": "www.ncbi.nlm.nih.gov",
      "host": "www.ncbi.nlm.nih.gov",
      "snippet": "Title: Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines - PMC\nBecause acute cholangitis sometimes rapidly progresses to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt diagnosis and s",
      "score": 0.8156003
    },
    {
      "number": 21,
      "title": "Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2784515",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "The clinical diagnosis of acute cholangitis is made on the basis of the clinical findings, such as Charcot’s triad,9 in combination with the laboratory data and imaging findings, and severity assessment is important because urgent biliary drainage is essential in “severe” cases. However, no standard",
      "score": 0.8145405
    },
    {
      "number": 22,
      "title": "Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. - Abstract",
      "detail": "pubmed.ncbi.nlm.nih.gov",
      "url": "https://pubmed.ncbi.nlm.nih.gov/17252299",
      "authors": "pubmed.ncbi.nlm.nih.gov",
      "host": "pubmed.ncbi.nlm.nih.gov",
      "snippet": "Biliary drainage is a radical method to relieve cholestasis, a cause of acute cholangitis, and takes a central part in the treatment of acute cholangitis. Emergent drainage is essential for severe cases, whereas patients with moderate and mild disease should also receive drainage as soon as possible",
      "score": 0.767847
    },
    {
      "number": 23,
      "title": "Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. - Abstract",
      "detail": "pubmed.ncbi.nlm.nih.gov",
      "url": "https://pubmed.ncbi.nlm.nih.gov/28941329",
      "authors": "pubmed.ncbi.nlm.nih.gov",
      "host": "pubmed.ncbi.nlm.nih.gov",
      "snippet": "grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be consider",
      "score": 0.74961954
    },
    {
      "number": 24,
      "title": "Study Details | NCT02107560 | Results of Bile and Blood Culture in Patients With Acute Cholangitis | ClinicalTrials.gov",
      "detail": "clinicaltrials.gov",
      "url": "https://clinicaltrials.gov/study/NCT02107560",
      "authors": "clinicaltrials.gov",
      "host": "clinicaltrials.gov",
      "snippet": "Click to view interactive map\n\n## Participation Criteria\n\nResearchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.  \n  \n For general information about clinical research, read L",
      "score": 0.5709301
    }
  ],
  "publishedAt": "2026-09-15T18:39:12.140800+00:00",
  "updatedAt": "2026-09-15T18:39:12.140800+00:00",
  "readingMinutes": 6,
  "slug": "acute-cholangitis-biliary-drainage"
}