Validation of Tokyo Guidelines 2018 for Cholangitis in an Australian Cohort

Abstract

Introduction: The Tokyo Guidelines 2018 (TG18) outline diagnostic and severity grading criteria for acute cholangitis, and recommends early biliary decompression. The application of TG18 to patients with cholangitis has not been validated in an Australian setting. This study evaluates the accuracy of the TG18 diagnostic criteria, the prognostic value of severity grading, and compares outcomes based on the timing of ERCP. Methods: A retrospective review of patients undergoing emergency ERCP for cholangitis in calendar years 2016-19 was performed at our hospital – we provide a high volume, surgeon-led ERCP service in Melbourne, Australia. TG18 diagnostic criteria was applied retrospectively to patients with clinically diagnosed cholangitis. TG18 severity grade, and time to ERCP, were compared with outcomes. Data was analysed using Fisher’s and T-tests. Results: 380 patients underwent ERCP for cholangitis. 301 had a clinical diagnosis of cholangitis – the TG18 diagnostic criteria demonstrated 99% diagnostic accuracy in this cohort. We also identified 79 patients who satisfied TG18 criteria but the diagnosis of 'cholangitis' was not recognised during admission – the mortality rate in this cohort was 4%, highlighting the value of a diagnostic criteria. Grade III cases had longer length-of-stay and more ICU admissions (p<0.0001). Early ERCP (<48hrs) was associated with shorter length-of-stay (p=0.0332) but on review of cases, mortality (1.8%) did not result from delay to ERCP. Conclusion: Our study demonstrates the accuracy of TG18 diagnostic criteria in an Australian population, and validates the prognostic value of its severity gradings. We report improved outcomes with early ERCP, and low cholangitis-associated mortality.EPLB005_Table 1Grading severity VS OutcomesOverallGrade I (Mild)Grade II (Moderate)Grade III (Severe)p-value (grade I vs III)p-value (GII vs III)In-hospital mortality1.8% (7/380)1.4% (1/71)0.87% (2/229)5% (4/80)0.37110.0409Hospital LOS (mean; days)8.76.6812.40.0001<0.0001ICU admission13.4% (51/380)7.0% (5/71)6.6% (15/229)38.8% (31/80)0.0001<0.0001ICU LOS (mean; days)1.02.82.74.30.36100.1008Timing to ERCP vs Outcomes, stratified by Grading severityHospital LOS (mean)Overall8.777.77.410.10.44640.0332Grade I6.65.75.85.98.10.56450.1901Grade II86.57.36.890.51930.1354Grade III12.410.110.51115.10.46100.1156 Open table in a new tab