title: TG13 flowchart for the management of acute cholangitis and cholecystitis.
abstract: We propose a management strategy for acute cholangitis and cholecystitis according to the severity assessment. For Grade I (mild) acute cholangitis, initial medical treatment including the use of antimicrobial agents may be sufficient for most cases. For non-responders to initial medical treatment, biliary drainage should be considered. For Grade II (moderate) acute cholangitis, early biliary drainage should be performed along with the administration of antibiotics. For Grade III (severe) acute cholangitis, appropriate organ support is required. After hemodynamic stabilization has been achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. In patients with Grade II (moderate) and Grade III (severe) acute cholangitis, treatment for the underlying etiology including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has been improved. In patients with Grade I (mild) acute cholangitis, treatment for etiology such as endoscopic sphincterotomy for choledocholithiasis might be performed simultaneously, if possible, with biliary drainage. Early laparoscopic cholecystectomy is the first-line treatment in patients with Grade I (mild) acute cholecystitis while in patients with Grade II (moderate) acute cholecystitis, delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobial agent is the first-line treatment. In non-responders to initial medical treatment, gallbladder drainage should be considered. In patients with Grade III (severe) acute cholecystitis, appropriate organ support in addition to initial medical treatment is necessary. Urgent or early gallbladder drainage is recommended. Elective cholecystectomy can be performed after the improvement of the acute inflammatory process. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
authors.affiliation: Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8605, Japan. f-miura@med.teikyo-u.ac.jp
authors.forename: Fumihiko
authors.initials: F
authors.lastname: Miura
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Takada
authors.forename: Steven M
authors.initials: SM
authors.lastname: Strasberg
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Solomkin
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.forename: O James
authors.initials: OJ
authors.lastname: Garden
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Masahiro
authors.initials: M
authors.lastname: Yoshida
authors.forename: Toshihiko
authors.initials: T
authors.lastname: Mayumi
authors.forename: Kohji
authors.initials: K
authors.lastname: Okamoto
authors.forename: Harumi
authors.initials: H
authors.lastname: Gomi
authors.forename: Shinya
authors.initials: S
authors.lastname: Kusachi
authors.forename: Seiki
authors.initials: S
authors.lastname: Kiriyama
authors.forename: Masamichi
authors.initials: M
authors.lastname: Yokoe
authors.forename: Yasutoshi
authors.initials: Y
authors.lastname: Kimura
authors.forename: Ryota
authors.initials: R
authors.lastname: Higuchi
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Yamashita
authors.forename: John A
authors.initials: JA
authors.lastname: Windsor
authors.forename: Toshio
authors.initials: T
authors.lastname: Tsuyuguchi
authors.forename: Toshifumi
authors.initials: T
authors.lastname: Gabata
authors.forename: Takao
authors.initials: T
authors.lastname: Itoi
authors.forename: Jiro
authors.initials: J
authors.lastname: Hata
authors.forename: Kui-Hin
authors.initials: KH
authors.lastname: Liau
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D002761:Cholangitis / Q000175:diagnosis / Q000628:therapy*; D041881:Cholecystitis, Acute / Q000175:diagnosis / Q000628:therapy*; D006801:Humans