Statistical & Clinical Analysis
Tokyo Guidelines (TG18) Acute Cholangitis Formula: Diagnosis & Grade I–III ERCP Triage
Apply the 2018 Tokyo Guidelines (TG18, Kiriyama et al.) diagnostic rule across Systemic Inflammation (A), Cholestasis (B), and Biliary Imaging (C) alongside Grade I, II, and III urgent ERCP biliary-drainage severity grading.
Why TG18 replaced low-sensitivity classic Charcot’s Triad (~26%–60%) with A+B+C diagnosis and 3-tier ERCP grading!
Jean-Martin Charcot’s 1877 triad (Fever + Jaundice + RUQ Pain) has high specificity (> 90%) but misses nearly half of acute cholangitis presentations! Seiki Kiriyama, Tadahiro Takada, et al. (2018, Journal of Hepato-Biliary-Pancreatic Sciences — Tokyo Guidelines TG18) standardized diagnosis across three domains: (A) Systemic Inflammation (fever/chills or abnormal WBC/CRP), (B) Cholestasis (total bilirubin >= 2 mg/dL or ALP/GGT/AST/ALT > 1.5 × ULN), and (C) Biliary Imaging (bile-duct dilatation or stone/stricture/stent etiology)—defining Definite Diagnosis when A + B + C are all positive, and Suspected Diagnosis when A + (either B or C) are positive!
Once diagnosed, TG18 stratifies biliary-drainage urgency into Grade III Severe (>= 1 organ dysfunction: cardiovascular vasopressors, neurological, PaO2/FiO2 < 300, creatinine > 2.0 mg/dL, INR > 1.5, or platelets < 100k -> urgent ERCP/PTBD + organ support), Grade II Moderate (>= 2 of: WBC > 12k or < 4k, Fever >= 39 °C, Age >= 75 yr, Total Bilirubin >= 5 mg/dL, Hypoalbuminemia < 0.7 × LLN -> early biliary drainage within 24–48 h), and Grade I Mild (antibiotics + elective/early drainage)!
| TG18 Diagnostic Domains (A, B, C) & Severity Counts | TG18 Diagnostic Certainty | TG18 Severity & Biliary Drainage Timing |
|---|---|---|
| A=1, B=1, C=1; Organ_Dysf=1 (Platelets 72k) | Definite Acute Cholangitis | Grade III Severe — Urgent ERCP / Biliary Drainage |
| A=1, B=1, C=1; Organ_Dysf=0, Moderate_Factors=3 | Definite Acute Cholangitis | Grade II Moderate — Early Drainage (< 24–48h) |
| A=1, B=1, C=1; Organ_Dysf=0, Moderate_Factors=1 | Definite Acute Cholangitis | Grade I Mild — Antimicrobials + Drainage Assessment |
TG18 Acute Cholangitis Severity Classifier (Grade III Severe, Grade II Moderate, Grade I Mild)
Evaluates diagnostic criteria (A=B2, B=B3, C=B4) and classifies confirmed/suspected cases by Organ Dysfunction count (B5 >= 1 -> Grade III) and Moderate Risk Factor count (B6 >= 2 -> Grade II).
=IF(OR(MIN(B2:B4) < 0, MAX(B2:B4) > 1, B5 < 0, B6 < 0, B6 > 5), "Invalid TG18 Inputs", IF(OR(B2 = 0, AND(B3 = 0, B4 = 0)), "Does Not Meet TG18 Cholangitis Criteria", IF(B5 >= 1, "Grade III Severe Cholangitis (Urgent Biliary Drainage + Organ Support)", IF(B6 >= 2, "Grade II Moderate Cholangitis (Early Endoscopic/Percutaneous Drainage)", "Grade I Mild Cholangitis (Antimicrobials & Standard Drainage)"))))TG18 Diagnostic Certainty Status (Definite A+B+C vs. Suspected A + B/C)
Distinguishes Definite Diagnosis (A=1, B=1, C=1) from Suspected Diagnosis (A=1 and B+C=1).
=IF(OR(MIN(B2:B4) < 0, MAX(B2:B4) > 1, B5 < 0, B6 < 0, B6 > 5), "Invalid TG18 Inputs", IF(AND(B2 = 1, B3 = 1, B4 = 1), "Definite TG18 Acute Cholangitis", IF(AND(B2 = 1, OR(B3 = 1, B4 = 1)), "Suspected TG18 Acute Cholangitis", "Does Not Meet TG18 Cholangitis Criteria")))Try the example
Use the original values or change them to test your understanding.