Unifying Concepts

Diagnostic Criteria for Cholangitis

Acute cholangitis, also referred to as ascending cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction. Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies.

Diagnostic criteria of acute cholangitis: Tokyo Guidelines

A. Clinical context and clinical manifestations

1. History of biliary disease
2. Fever and/or chills
3. Jaundice
4. Abdominal pain (right upper quadrant or upper abdominal)

B. Laboratory data

5. Evidence of inflammatory responsea
6. Abnormal liver function testsb

C. Imaging findings

7. Biliary dilatation, or evidence of an etiology (stricture, stone, stent etc)

Suspected diagnosis Two or more items in A

Definite diagnosis

(1) Charcot’s triad (2 + 3 + 4)
(2) Two or more items in A + both items in B and item C

a Abnormal WBC count, increase of serum C-reactive protein (CRP) level, and other changes indicating inflammation
b Increased serum ALP, r-GTP (GGT), AST, and ALT levels

Criteria for severity assessment of acute cholangitis: Tokyo Guidelines

Severity of acute cholangitis
Criterion Mild (grade I) Moderate (grade II) Severe (grade III)
Onset of organ dysfunction No No Yes
Response to initial medical treatmenta Yes No No
a Consisting of general supportive care and antibiotics


Definitions of severity assessment criteria for acute cholangitis

Mild (grade I) acute cholangitis
“Mild (grade I)” is defined as acute cholangitis that is responsive to initial medical treatment.

Moderate (grade II) acute cholangitis
“Moderate (grade II)” acute cholangitis is defined as acute cholangitis that does not respond to the initial medical treatmenta and is not accompanied by organ dysfunction

Severe (grade III) acute cholangitis
“Severe (grade III)” acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems:

  1. Cardiovascular system: Hypotension requiring dopamine >/= 5 ug/kg per min, or any dose of dobutamine
  2. Nervous system: Disturbance of consciousness
  3. Respiratory system: PaO2/FiO2 ratio < 300
  4. Kidney: Serum creatinine > 2.0 mg/dl
  5. Liver: PT-INR > 1.5
  6. Hematological system: Platelet count < 100 000 /ul

Note: compromised patients, e.g., elderly (>75 years old) and patients with medical comorbidities, should be monitored closely
a General supportive care and antibiotics


  1. Lee CC, Chang IJ, Lai YC, Chen SY, Chen SC. Epidemiology and prognostic determinants of patients with bacteremic cholecystitis or cholangitis. Am. J. Gastroenterol. 2007 Mar;102(3):563-9. [Medline]
  2. Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida M, Mayumi T, Strasberg S, Pitt HA, Gadacz TR, Büchler MW, Belghiti J, de Santibanes E, Gouma DJ, Neuhaus H, Dervenis C, Fan ST, Chen MF, Ker CG, Bornman PC, Hilvano SC, Kim SW, Liau KH, Kim MH. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):52-8. [Medline]
Created: Jul 16, 2007
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