Unifying Concepts

TG18/TG13 Diagnostic Criteria for Acute Cholangitis

The diagnostic and severity grading criteria on the 2018 Tokyo Guidelines (TG18) are used worldwide as the primary standard for management of acute cholangitis (AC).

TG18/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



A‐2: Abnormal white blood cell counts, increase of serum C‐reactive protein levels, and other changes indicating inflammation

B‐2: Increased serum ALP, r‐GTP (GGT), AST, and ALT levels

Other factors which are helpful in diagnosis of acute cholangitis include abdominal pain (right upper quadrant 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.

A‐1 Fever: BT >38°C
A‐2 Evidence of inflammatory response: WBC count (×1,000/μL) <4 or >10; CRP (mg/dL) ≥1
B‐1 Jaundice: T‐Bil ≥2 (mg/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*

Abbreviations: ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, CRP C‐reactive protein, r‐GTP (GGT) r‐glutamyltransferase, WBC white blood cell, BT body temperature.
* STD: upper limit of normal value



  1. Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, Hata J, Liau KH, Miura F, Horiguchi A, Liu KH, Su CH, Wada K, Jagannath P, Itoi T, Gouma DJ, Mori Y, Mukai S, Giménez ME, Huang WS, Kim MH, Okamoto K, Belli G, Dervenis C, Chan ACW, Lau WY, Endo I, Gomi H, Yoshida M, Mayumi T, Baron TH, de Santibañes E, Teoh AYB, Hwang TL, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Higuchi R, Kitano S, Inomata M, Deziel DJ, Jonas E, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. [Medline]
  2. Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, Kozaka K, Endo I, Deziel DJ, Miura F, Okamoto K, Hwang TL, Huang WS, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Noguchi Y, Shikata S, Ukai T, Higuchi R, Gabata T, Mori Y, Iwashita Y, Hibi T, Jagannath P, Jonas E, Liau KH, Dervenis C, Gouma DJ, Cherqui D, Belli G, Garden OJ, Giménez ME, de Santibañes E, Suzuki K, Umezawa A, Supe AN, Pitt HA, Singh H, Chan ACW, Lau WY, Teoh AYB, Honda G, Sugioka A, Asai K, Gomi H, Itoi T, Kiriyama S, Yoshida M, Mayumi T, Matsumura N, Tokumura H, Kitano S, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. [Medline]
  3. Gravito-Soares E, Gravito-Soares M, Gomes D, Almeida N, Tomé L. Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model. Scand J Gastroenterol. 2018 Mar;53(3):329-334. [Medline]


Created Oct 19, 2018.

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