Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis

J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40. doi: 10.1002/jhbp.509. Epub 2018 Jan 8.


The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. 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/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 considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: Related clinical questions and references are also included.

Keywords: Acute cholangitis; Acute cholecystitis; Biliary drainage; Guidelines; Initial treatment.

Publication types

  • Letter
  • Review

MeSH terms

  • Acute Disease
  • Anti-Bacterial Agents / therapeutic use
  • Cholangitis / diagnostic imaging*
  • Cholangitis / pathology
  • Cholangitis / therapy*
  • Cholecystitis, Acute / diagnostic imaging*
  • Cholecystitis, Acute / pathology
  • Cholecystitis, Acute / therapy*
  • Clinical Decision-Making
  • Drainage / methods
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Monitoring, Physiologic / methods
  • Practice Guidelines as Topic*
  • Risk Assessment
  • Severity of Illness Index
  • Software Design
  • Sphincterotomy, Endoscopic / methods*
  • Tokyo
  • Treatment Outcome


  • Anti-Bacterial Agents