Progression of Tokyo Guidelines and Japanese Guidelines for Management of Acute Cholangitis and Cholecystitis

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1 J UOEH 35( 4 ): (2013) 249 [Review] Progression of Tokyo Guidelines and Japanese Guidelines for Management of Acute Cholangitis and Cholecystitis Toshihiko Mayumi 1*, Kazuki Someya 1, Hiroki Ootubo 1, Tatsuo Takama 1, Takashi Kido 1, Fumihiko Kamezaki 1, Masahiro Yoshida 2 and Tadahiro Takada 3 1 Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan. Yahatanishi-ku Kitakyushu , Japan 2 Clinical Research Center Kaken Hospital, International University of Health and Welfare, Koufudai Ichikawa , Japan 3 Department of Surgery, School of Medicine, Teikyo University, Kaga, Itabashi-ku , Japan Abstract : The Japanese Guidelines for management of acute cholangitis and cholecystitis were published in 2005 as the first practical guidelines presenting diagnostic and severity assessment criteria for these diseases. After the Japanese version, the Tokyo Guidelines (TG07) were reported in 2007 as the first international practical guidelines. There were some differences between the two guidelines, and some weak points in TG07 were pointed out, such as low sensitivity for diagnosis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. Therefore, revisions were started to not only make them up to date but also concurrent with the same diagnostic and severity assessment criteria. The Revision Committee for the revision of TG07 (TGRC) performed validation studies of TG07 and new diagnostic and severity assessment criteria of acute cholangitis and cholecystitis. These were retrospective multi-institutional studies that collected cases of acute cholangitis, cholecystitis, and non-inflammatory biliary disease. TGRC held 35 meetings as well as international exchanges with co-authors abroad and held three International Meetings. Through these efforts, TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The worldʼs first management bundles of acute cholangitis and cholecystitis were also presented. The revised Japanese version was published with the same content as TG13. An electronic application of TG13 that can help to diagnose and assess the severity of these diseases using the criteria of TG13 was made for free download. Keywords : practice guidelines, acute cholangitis, acute cholecystitis, management bundles, antibiotics. (Received July 8, 2013, accepted October 18, 2013) What are practice guidelines? If all interventions were standardized, there would be no need for practice guidelines, but, in any medical fields, when new diagnostic and therapeutic methods are developed some controversy over them may occur. If there were a best practice, discrepancies in these interventions might result in poor medical care for patients. Practice guidelines are made to improve patientsʼ outcome, disseminating current good practices, but some medical staff fear that if they did not follow the guidelines they might be sued. Although medical staff need to explain the contents of the guidelines to patients *Corresponding Author: Toshihiko Mayumi, MD, Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Yahatanishi-ku, Kitakyushu, Fukuoka , Japan. Tel: , Fax: , mtoshi@med.uoeh-u.ac.jp

2 250 T Mayumi et al and patientsʼ family, interventions should be chosen not only by evidence, but also with the approval of the patients/family and by the medical circumstance of the institution. Therefore, following the guidelines in any and all situations is not necessarily the best practice. The Japanese Guidelines for management of acute cholangitis and cholecystitis 2003 There were no practical guidelines, evidence-basedcriteria for diagnosis, or severity assessment of treatment of acute cholecystitis or acute cholangitis before Although Charcotʼs triad and Reynoldsʼ pentad are well known, the full complement of symptoms and signs described in these criteria are infrequent and not useful in clinical management strategies [1]. In these circumstances, a project committee began to prepare evidence-based guidelines for the management of acute cholangitis and cholecystitis. This work was funded by the Japanese Ministry of Health, Labour, and Welfare, in cooperation with the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary- Pancreatic Surgery. The working group, consisting of 46 experts in gastroenterology, surgery, internal medicine, emergency medicine, intensive care, and clinical epidemiology, analyzed and examined the literature on patients with acute cholangitis and cholecystitis in order to produce evidence-based guidelines. There was a lack of high-level evidence in these fields, and the working group formulated the guidelines by obtaining consensus, based on best evidence. This work required more than 20 meetings to obtain a consensus within the working group on each item. Following that, four forums were held to permit examination of the Guideline details in Japan to an audience in order to collect public comments. After these efforts, the Japanese Guidelines for management of acute cholangitis and cholecystitis and diagnostic and severity assessment criteria for these diseases were published in 2005 as the first practice guidelines in the world. Tokyo Guidelines for management of acute cholangitis and cholecystitis 2007 As a next step, we attempted to make worldwide practice guidelines for acute cholangitis and cholecystitis. Since the diagnosis and management of acute biliary infection may differ from country to country, we appointed a publication committee and held 12 meetings to prepare draft guidelines in English. We then had several discussions on these draft guidelines with leading experts in the field throughout the world, via . Finally, an International Consensus Meeting took place in Tokyo, on April 1st 2nd, 2006, to obtain international agreement on diagnostic criteria, severity assessment, and management strategies [2]. With minor modifications after the international meeting, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the first international practice guidelines for these diseases [3-6]. TG07 has not only diagnostic and severity assessment criteria, but also f lowcharts, epidemiology, and several kinds of techniques of biliary drainage and surgical methods [6-10]. Distribution of Tokyo Guidelines for management of acute cholangitis and cholecystitis 2007 After the publication of TG07, the criteria for diagnosis and severity assessment criteria were frequently used in new clinical studies of acute cholangitis and cholecystitis, and citations of TG07 increased [11]. These were referred to in a text book [12, 13], in a review in the New England Journal of Medicine [14], and in the Guidelines for Diagnosis and management of complicated intra-abdominal infection by the Surgical Infection Society and the Infectious Diseases Society of America [15]. Also, it was reported that compliance with the TG07 was correlated with good outcomes of patients with acute cholangitis [16]. Japanese Guidelines 2005 (JG05) and Tokyo Guidelines 2007 (TG07) in clinical practice On the other hand, critical appraisal of TG07 showed problems in applying it in clinical settings. First, the sensitivity of acute cholangitis was low [17]. Second, since mild and moderate acute cholangitis can be distinguished only 24 hrs after initial medical treatment in TG07, the criteria is impractical for deciding the timing of biliary drainage [18, 19].

3 Progression of Tokyo Guidelines 251 Since the diagnostic and severity assessment criteria and the flowchart were different between the two guidelines, these discrepancies led to confusion and misinterpretation in Japan. Tokyo Guidelines 2013 (TG13) To update and correct these defects in the Japanese Guidelines 2005 (JG05) and the Tokyo Guidelines 2007 (TG07), we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) in June 2010 and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of noninflammatory biliary disease, collected from multiple institutions [1, 20]. TGRC held 35 committee meetings, and three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines in Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of evidence from retrospective multi-center analyses and were published in 2013 [11]. To be specific, discussion took place involving the revised new diagnostic and severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention (Table 1, 2) (Fig. 1, 2) [21-27]. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice [21, 22]. The sensitivity improved from 82.8% (TG07) to 91.8% (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 (TG07) to 5.9% (TG13). Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. Free full-text articles and a mobile application of TG13 are available via jp/en/guideline/tg13.html (Fig. 3). Table 1. TG13 diagnostic criteria for acute cholangitis A. Systemic inflammation A-1. Fever and/or shaking chills A-2. Laboratory data: evidence of inflammatory response B. Cholestasis B-1. Jaundice B-2. Laboratory data: abnormal liver function tests C. Imaging C-1. Biliary dilatation C-2. Evidence of the etiology on imaging (stricture, stone, stent etc.) Suspected diagnosis: One item in A + one item in either B or C Definite diagnosis: One item in A, one item in B and one item in C Thresholds A-1 Fever BT > 38 A-2 Evidence of inflammatory response WBC ( 1000/µl) < 4, or > 10 CRP (mg/dl) 1 B-1 Jaundice T-Bil 2 (g/dl) B-2 Abnormal liver function tests ALP (IU) > 1.5 STD γgtp (IU) > 1.5 STD AST (IU) > 1.5 STD ALT (IU) > 1.5 STD Note: A-2: Abnormal white blood cell counts, increase of serum C-reactive protein levels, and other changes indicating inflammation. B-2: Increased serum ALP, γgtp (GGT), AST and ALT levels. Other factors which are helpful in diagnosis of acute cholangitis include abdominal pain [right upper quadrant (RUQ) or upper abdominal] and a history of biliary disease such as gallstones, previous biliary procedures, and placement of a biliary stent. In acute hepatitis, marked systematic inflammatory response is observed infrequently. Virological and serological tests are required when differential diagnosis is difficult. STD: upper limit of normal value, BT: body temparature, WBC: white blood cell count, CRP: C-reactive protein, T-Bil: toital birirubin, ALP: alkaline phosphatase, cgtp (GGT): c-glutamyltransferase, AST: aspartate aminotransferase, ALT: alanine aminotransferase, Reproduced from ref. Kiriyama S et al (2013): J Hepatobiliary Pancreat Sci 20: [21] with permission of the Springer Science

4 252 T Mayumi et al Table 2. TG13 severity assessment criteria for acute cholangitis Grade III (Severe) acute cholangitis ʻʻ Grade IIIʼʼ acute cholangitis is defined as cholangitis that is associated with the onset of dysfunction in at least one of any of the following organs/systems: 1. Cardiovascular dysfunction Hypotension requiring dopamine > 5 μg/kg per min, or any dose of norepinephrine 2. Neurological dysfunction Disturbance of consciousness 3. Respiratory dysfunction PaO 2/FiO 2 ratio < Renal dysfunction Oliguria, serum creatinine > 2.0 mg/dl 5. Hepatic dysfunction PT-INR > Hematological dysfunction Platelet count < 100,000 / mm 3 Grade II (moderate) acute cholangitis ʻʻ Grade IIʼʼ acute cholangitis is associated with any two of the following conditions: 1. Abnormal WBC count ( > 12,000 / mm 3, < 4,000 / mm 3 ) 2. High fever ( 39 C) 3. Age ( 75 years old) 4. Hyperbilirubinemia (total bilirubin 5 mg/dl) 5. Hypoalbuminemia ( < STD 0.7) Grade I (mild) acute cholangitis ʻʻ Grade Iʼʼ acute cholangitis does not meet the criteria of ʻʻGrade III (severe)ʼʼ or ʻʻGrade II (moderate)ʼʼ acute cholangitis at initial diagnosis. Notes: Early diagnosis, early biliary drainage and/or treatment for etiology, and antimicrobial administration are fundamental treatments for acute cholangitis classified not only as Grade III (severe) and Grade II (moderate) but also Grade I (mild). Therefore, it is recommended that patients with acute cholangitis who do not respond to the initial medical treatment (general supportive care and antimicrobial therapy) undergo early biliary drainage or treatment for etiology (see flowchart). STD: lower limit of normal value, Reproduced from ref. Kiriyama S et al (2013): J Hepatobiliary Pancreat Sci 20: [21] with permission of the Springer Science. Diagnosis and Severity Assessment by TG13 Guidelines Grade I (Mild) Grade II (Moderate) Grade III (Severe) Treatment According to Grade, According to Response, and According to Need for Additional Therapy and General Supportive Care Early Biliary Drainage General Supportive Care Urgent Biliary Drainage Organ Support Finish course of antibiotics Biliary Drainage Treatment for etiology if still needed (Endoscopic treatment, percutaneous treatment, or surgery) Fig. 1. Flowchart for the management of acute cholangitis: TG13. : Performance of a blood culture should be taken into consideration before initiation of administration of antibiotics. A bile culture should be performed during biliary drainage, : Principle of treatment for acute cholangitis consists of antimicrobial administration and billary drainage including treatment for etiology. For patient with choledocholithiasis, treatment for etiology might be performed simultaneously, if possible, with biliary drainage. Reproduced from ref. Miura F et al (2013): J Hepatobiliary Pancreat Sci 20: [23] with permission of the Springer Science.

5 Progression of Tokyo Guidelines 253 Diagnosis and Severity Assessment by TG13 Guidelines Treatment According to Grade and According to Response Observation Grade I (Mild) Grade II (Moderate) Grade III (Severe) and General Supportive Care and General Supportive Care and General Organ Support Advanced laparoscopic technique available Failure therapy Successful therapy Urgent/early GB drainage Early LC Emergency Surgery Delayed/ Elective LC Fig. 2. Flowchart for the management of acute cholangitis: TG13. LC: laparoscopic cholecystectomy, GB: gallbladder, : Performance of a blood culture should be taken into consideration before initiation of administration of antibiotics, : A bile culture should be performed during GB drainage. Reproduced from ref. Miura F et al (2013): J Hepatobiliary Pancreat Sci 20: [23] with permission of the Springer Science. PDF are downloadable for free from (Springer Link) or (JSHBPS HP) Fig. 3. Download of Application and Tokyo Guidelines.

6 254 T Mayumi et al Management bundles for acute cholangitis and cholecystitis in TG13 Table 3. Management bundle of acute cholangitis 1. When acute cholangitis is suspected, diagnostic assessment is made using TG13 diagnostic criteria every 6-12 h 2. Abdominal X-ray (KUB) and abdominal US are carried out, followed by CT scan, MRI, MRCP and HIDA scan 3. Severity is repeatedly assessed using severity assessment criteria; at diagnosis, within 24 h after diagnosis, and during the time zone of h 4. As soon as a diagnosis has been made, the initial treatment is provided. The treatment is as follows: sufficient fluids replacement, electrolyte compensation, and intravenous administration of analgesics and full dose of antimicrobial agents are provided 5. For patients with Grade I (mild), when no response to the initial treatment is observed within 24 h, biliary tract drainage is carried out immediately 6. For patients with Grade II (moderate), biliary tract drainage is immediately performed along with the initial treatment. If early drainage cannot be performed due to the lack of facilities or skilled personnel, transfer of the patient is considered 7. For patients with Grade III (severe), urgent biliary tract drainage is performed along with the initial treatment and general supportive care. If urgent drainage cannot be performed due to the lack of facilities or skilled personnel, transfer of the patient is considered 8. For patient with Grade III (severe), organ supports (noninvasive/invasive positive pressure ventilation, use of vasopressors and antimicrobial agents, etc.) are immediately performed 9. Blood culture and/or bile culture is performed for Grade II (moderate) and III (severe) patients 10. Treatment for etiology of acute cholangitis with endoscopic, percutaneous, or operative intervention is considered once acute illness has resolved. Cholecystectomy should be performed for cholecystolithiasis after acute cholangitis has resolved KUB: kidney ureter bladder, US: ultrasonography, CT: computed tomography, MRI: magnetic resonance imaging, MRCP: magnetic resonance cholangiopancreatography, HIDA: hepatobiliary iminodiacetic acid. Reproduced from ref. Okamoto K et al (2013): J Hepatobiliary Pancreat Sci 20: [28] with permission of the Springer Science. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination of the guidelinesʼ recommendations for the first time in the world (Table 3, 4) [28]. Adherence to these bundles is a great indicator of the distribution of the guidelines, and the correlations with adherence to these bundles and the patientsʼ prognosis are also good indicators of the effectiveness of the guidelines. For the convenience of clinicians, a checklist of the bundles has also been prepared to confirm compliance with the bundles of TG13. Table 4. Management bundle of acute cholecystitis 1. When acute cholecystitis is suspected, diagnostic assessment is made using TG13 diagnostic criteria every 6-12 h 2. Abdominal US is carried out, followed by HIDA scan and CT scan if needed to make the diagnosis 3. Severity is repeatedly assessed using severity assessment criteria; at diagnosis, within 24 h after diagnosis, and during the time zone of h 4. Taking into consideration that cholecystectomy is performed, as soon as a diagnosis has been made, the initial treatment takes place involving the replacement of sufficient fluid after fasting, electrolyte compensation, intravenous injection of analgesics and full dose antimicrobial agents 5. For patients with Grade I (mild), cholecystectomy at an early stage within 72 h of onset of symptoms is recommended 6. If conservative treatment patients with Grade I (mild) is selected and no response to the initial treatment is observed within 24 h, reconsider early cholecystectomy if still within 72 h of onset of symptoms or biliary tract drainage 7. For patients with Grade II (moderate), perform immediate biliary drainage or drainage if no early improvement (or cholecystectomy in experienced centers) along with the initial treatment 8. For patients with Grade II (moderate) and III (severe) at high surgical risk, biliary drainage is immediately carried out 9. Blood culture and/or bile culture is performed for Grade II (moderate) and III (severe) patients 10. Among patients with Grade II (moderate), for those with serious local complications including biliary peritonitis, pericholecystic abscess, liver abscess or for those with gallbladder torsion, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis, emergency surgery is conducted (open or laparoscopic depending on experience) along with the general supportive care of the patient. If surgery cannot be performed due to the lack of facilities or skilled personnel, transfer of the patient is considered 11. For patients with Grade III (severe) with jaundice and those in poor general conditions, emergency gallbladder drainage is considered with initial therapy with antibiotics and general support measures. For patients who are found to have gallbladder stones during biliary drainage, cholecystectomy is performed at after 3 month interval after the patientʼs general conditions are improved US: ultrasonography, CT: computed tomography, HIDA: hepatobiliary iminodiacetic acid. Reproduced from ref. Okamoto K et al (2013): J Hepatobiliary Pancreat Sci 20: [28] with permission of the Springer Science.

7 Progression of Tokyo Guidelines 255 The Japanese Guidelines 2013 (JG13) After finishing the final draft of TG13, a revision of the Japanese Guidelines 2013 (JG13) was begun with TGRC. To avoid making double standards, as between JG05 and TG07, main schema, such as diagnostic and severity assessment criteria, flow charts, and recommendations were set the same as TG13. Little was modified from TG13 according to Japanese medical situations, such as the availability of antibiotics. JG13 was published in Japanese in March 2013 as a book. Computer Application for TG13 To distribute TG13, we made a computer application that can help to diagnose and assess the severity of acute cholangitis and cholecystitis using the criteria of TG13. This Application also shows flowcharts and recommended antibiotics, and can be downloaded for free (Fig. 3). Conclusions The Japanese and Tokyo Guidelines for acute cholangitis and cholecystitis were revised in 2013 with a retrospective multi-center analysis of these disease and non-inflammatory biliary disease. These studies and many revised international meetings lead to the adaption of these guidelines to clinical management of these disease. We hope that the management bundles and computer application of these guidelines will be distributed to medical staff and will aid the diagnosis and severity assessment of acute cholangitis and cholecystitis and improve the outcome of patients. References 1. Kiriyama S, Takada T, Strasberg SM et al (2012): New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci 19: Mayumi T, Takada T, Kawarada Y et al (2007): Results of the tokyo consensus meeting Tokyo Guidelines, J Hepatobiliary Pancreat Surg 14: Takada T, Kawarada Y, Nimura Y et al (2007): Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg 14: Wada K, Takada T, Kawarada Y et al (2007): Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Hirota M, Takada T, Kawarada Y et al (2007): Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Miura F, Takada T, Kawarada Y et al (2007): Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Sekimoto M, Takada T, Kawarada Y et al (2007): Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Tsuyuguchi T, Takada T, Kawarada Y et al (2007): Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Tsuyuguchi T, Takada T, Kawarada Y et al (2007): Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Yamashita Y, Takada T, Kawarada Y et al (2007): Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14: Takada T, Strasberg SM, Solomkin JS et al (2013): TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20: Cameron JL & Cameron AM (2011): Current Surgical Therapy. 10th ed. Elsevier Mosby, Philadelphia, 1392 pp 13. Dooley JS, Lok A, Burroughs A & Heathcote J (2011): Sherlockʼs diseases of the liver and biliary system, 12th ed. Blackwell, Hoboken, 792 pp 14. Strasberg SM (2008): Clinical practice. Acute calculous cholecystitis. N Engl J Med 358: Solomkin JS, Mazuski JE, Bradley JS et al (2010): Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society Of America. Clin Infect Dis 50:

8 256 T Mayumi et al 16. Murata A, Matsuda S, Kuwabara K, Fujino Y, Kubo T, Fujimori K & Horiguchi H (2011): Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system. J Hepatobiliary Pancreat Sci 18: Yokoe M, Takada T, Mayumi T, Yoshida M, Hasegawa H, Norimizu S, Hayashi K, Umemura S & Orito E (2011): Accuracy of the Tokyo Guidelines for the diagnosis of acute cholangitis and cholecystitis taking into consideration the clinical practice pattern in Japan. J Hepatobiliary Pancreat Sci 18: Fujii Y, Ohuchida J, Chijiiwa K, Yano K, Imamura N, Nagano M, Hiyoshi M, Otani K, Kai M & Kondo K (2012): Verification of Tokyo Guidelines for diagnosis and management of acute cholangitis. J Hepatobiliary Pancreat Sci 19: Tsuyuguchi T, Sugiyama H, Sakai Y, Nishikawa T, Yokosuka O, Mayumi T, Kiriyama S, Yokoe M & Takada T (2012): Prognostic factors of acute cholangitis in cases managed using the Tokyo Guidelines. J Hepatobiliary Pancreat Sci 19: Yokoe M, Takada T, Strasberg SM et al (2012): New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci 19: Kiriyama S, Takada T, Strasberg SM et al (2013): TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 20: Yokoe M, Takada T, Strasberg SM et al (2013): TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 20: Miura F, Takada T, Strasberg SM et al (2013): TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20: Gomi H, Solomkin JS, Takada T et al (2013): TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20: Tsuyuguchi T, Itoi T, Takada T et al (2013): TG13 indications and techniques for gallbladder drainage in acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 20: Itoi T, Tsuyuguchi T, Takada T et al (2013): TG13 indications and techniques for biliary drainage in acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 20: Yamashita Y, Takada T, Strasberg SM et al (2013): TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 20: Okamoto K, Takada T, Strasberg SM et al (2013): TG13 management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20: 55-59

9 Progression of Tokyo Guidelines 257 急性胆管炎 胆嚢炎診療ガイドライン日本版と Tokyo Guidelines 真弓俊彦 1, 染谷一貴 1, 大坪広樹 1, 高間辰雄 1, 城戸貴志 1, 亀崎文彦 1, 吉田雅博 2, 3 高田忠敬 1 産業医科大学医学部救急医学 2 国際医療福祉大学化学療法研究所附属病院人工透析 一般外科 3 帝京大学医学部外科 要旨 :2005 年に急性胆管炎 胆嚢炎診療ガイドラインを作成し, 初めてこれらの診断 重症度判定基準を定め, 2007 年に初の国際的なガイドライン Tokyo Guidelines (TG07) として発刊したしかし, 両者には相違があり, また, TG07 は胆管炎診断の感度が低いことやガイドラインと実臨床とのギャップも指摘されたそこで, 新知見を加えるとともに, 両ガイドラインで同一の診断 重症度判定基準を策定することとなった 改訂委員会を組織し, 多施設で急性胆道炎と非胆道炎症例を集積し,TG07 の妥当性を検証し, 新たな診断 重症度判定基準を作成した 国際的な意見交換,3 回の国際検討会,35 回の改訂委員会を開催したこれらを経て,TG13 の診断基準の感度は上がり, 偽陽性は減少し, 重症度も臨床に即したものとなった 世界初の急性胆道炎の診療バンドルも新たに設けた 日本語版も TG13 に沿って改訂し, 診断, 重症度判定, 抗菌薬選択に有用なアプリも開発し, 無料でダウンロード可能である キーワード : 診療ガイドライン, 急性胆管炎, 急性胆嚢炎, 診療バンドル, 抗菌薬 J UOEH( 産業医科大学雑誌 )35(4): (2013)