Dr. Elizabeth Squirell

Acute cholangitis (Tokyo 2018)

TG18 diagnosis and severity grade, with drainage timing and antibiotics

Reviewed October 2026

For healthcare professionals. A decision aid, not a substitute for clinical judgement.

Tokyo 2018 (TG18): one item from A plus one from B or C is suspected cholangitis; A, B and C together are definite. Severity questions appear once the criteria are met.

A · Systemic inflammation

One item from A is always needed.

TemperatureFever is above 38 °C. 39 °C or more is also a Grade II factor.
°C
Shaking chills (rigors)
White cell countBelow 4 or above 10 meets A-2. Below 4 or above 12 is a Grade II factor.
×10⁹/L
CRP (optional)10 mg/L (1 mg/dL) or more meets A-2. Leave blank if not measured: A-2 then rests on the white count.
mg/L

B · Cholestasis

Total bilirubinJaundice is ≥34.2 µmol/L (2 mg/dL); ≥85.5 µmol/L (5 mg/dL) is a Grade II factor.
µmol/L
Liver enzymes above 1.5 × the upper limit of normal?Any of ALP, GGT, AST or ALT.

C · Imaging

Ultrasound, CT or MRCP.

Biliary dilatation
Cause seen on imagingStone, stricture, stent or other obstruction.

Tokyo Guidelines 2018

Answer 7 more items to see the result.

  • Temperature
  • Shaking chills
  • White cell count
  • Total bilirubin
  • Liver enzymes >1.5 × ULN
  • Biliary dilatation on imaging
  • Cause seen on imaging

How to use it

Work down the form. A (inflammation) is always needed. With B (cholestasis) or C (imaging) it is suspected cholangitis; with both it is definite. Once the criteria are met, the severity questions appear. If you enter an organ dysfunction early, the tool warns you straight away that the patient is Grade III.

Bilirubin and creatinine take µmol/L or mg/dL. TG18 thresholds are in mg/dL; this tool converts exactly (bilirubin ÷17.1, creatinine ÷88.4), so 2 mg/dL is 34.2 µmol/L and a bilirubin of 34 µmol/L does not meet B-1.

Reading the result

Grade Definition Drainage
III (severe) Any organ dysfunction: vasopressors, altered consciousness, PaO2/FiO2 <300, oliguria or creatinine >176.8 µmol/L, INR >1.5, platelets <100 As soon as possible after resuscitation; within 12 h if septic shock (ESGE 2019)
II (moderate) Two of: WBC >12 or <4, temperature ≥39 °C, age ≥75, bilirubin ≥85.5 µmol/L, albumin <0.7 × LLN Early: within 48 h (ASGE 2021) or 48–72 h (ESGE 2019)
I (mild) Neither Antibiotics; drain if no response, otherwise elective (TG18, ESGE)

Guidelines differ on Grade II timing. ESGE says 48–72 h; ASGE says within 48 h. This tool shows both and suggests aiming for 48 h.

Antibiotics. Take blood cultures and start empirical antibiotics promptly. TG18 recommends 4–7 days once the source is controlled, and at least 2 weeks when blood cultures grow Gram-positive cocci such as Enterococcus. Shorter courses after good drainage are being tested (for example the Dutch COBRA trial of 1 day vs 4–7 days).

Pitfalls

  • Grade is set at the first assessment. Patients can worsen. Regrade if they deteriorate.
  • Older adults may not mount a fever. A normal temperature does not exclude cholangitis if the white count or CRP is abnormal.
  • “Not met” is not “ruled out”. Findings can be missing early in the illness. Reassess and repeat imaging if the picture changes.
  • Acute hepatitis can mimic cholestasis but rarely causes a marked systemic inflammatory response; check viral and autoimmune serology when unsure.
  • After ERCP for stones, ESGE recommends laparoscopic cholecystectomy within 2 weeks to cut recurrent biliary events.

Try “pregnancy”, “Mayo”, “calprotectin” or “VARSITY”.