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Review
. 2023 Oct;11(8):767-774.
doi: 10.1002/ueg2.12402. Epub 2023 Jul 18.

Invalidity of Tokyo guidelines in acute biliary pancreatitis: A multicenter cohort analysis of 944 pancreatitis cases

Márk Félix Juhász  1   2 , Rebeka Tóháti  3 , Viktória Adrienn Jászai  3 , Regina Molnár  3 , Nelli Farkas  1   4 , László Czakó  5 , Áron Vincze  6 , Bálint Erőss  1   7   8 , Andrea Szentesi  1 , Ferenc Izbéki  9 , Mária Papp  10 , Péter Hegyi  1   7   8 , Andrea Párniczky  1   2   8 ; Hungarian Pancreatic Study Group
Collaborators, Affiliations
Review

Invalidity of Tokyo guidelines in acute biliary pancreatitis: A multicenter cohort analysis of 944 pancreatitis cases

Márk Félix Juhász et al. United European Gastroenterol J. 2023 Oct.

Abstract

Background: There is a noteworthy overlap between the clinical picture of biliary acute pancreatitis (AP) and the 2018 Tokyo guidelines currently used for the diagnosis of cholangitis (AC) and cholecystitis (CC). This can lead to significant antibiotic and endoscopic retrograde cholangiopancreatography (ERCP) overuse.

Objectives: We aimed to assess the on-admission prevalence of AC/CC according to the 2018 Tokyo guidelines (TG18) in a cohort of biliary AP patients, and its association with antibiotic use, ERCP and clinically relevant endpoints.

Methods: We conducted a secondary analysis of the Hungarian Pancreatic Study Group's prospective multicenter registry of 2195 AP cases. We grouped and compared biliary cases (n = 944) based on the on-admission fulfillment of definite AC/CC according to TG18. Aside from antibiotic use, we evaluated mortality, AC/CC/AP severity, ERCP performance and length of hospitalization. We also conducted a literature review discussing each criteria of the TG18 in the context of AP.

Results: 27.8% of biliary AP cases fulfilled TG18 for both AC and CC, 22.5% for CC only and 20.8% for AC only. Antibiotic use was high (77.4%). About 2/3 of the AC/CC cases were mild, around 10% severe. Mortality was below 1% in mild and moderate AC/CC patients, but considerably higher in severe cases (12.8% and 21.2% in AC and CC). ERCP was performed in 89.3% of AC cases, common bile duct stones were found in 41.1%.

Conclusion: Around 70% of biliary AP patients fulfilled the TG18 for AC/CC, associated with a high rate of antibiotic use. Mortality in presumed mild or moderate AC/CC is low. Each of the laboratory and clinical criteria are commonly fulfilled in biliary AP, single imaging findings are also unspecific-AP specific diagnostic criteria are needed, as the prevalence of AC/CC are likely greatly overestimated. Randomized trials testing antibiotic use are also warranted.

Keywords: 2018 Tokyo guidelines; ERCP; antibiotic use; biliary acute pancreatitis; cholangitis; cholecystitis; endoscopic retrograde cholangiopancreatography; mortality; stones.

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Conflict of interest statement

The authors declare that there is no conflict of interest.

Figures

FIGURE 1
FIGURE 1
Cholangitis and cholecystitis severity's influence on acute pancreatitis. The figure displays the distribution of cholangitis and cholecystitis severity and antibiotic use, length of hospitalization, acute pancreatitis severity, and mortality in the mild, moderate and severe cholangitis and cholecystitis subgroups. %, percentage; AC, acute cholangitis; AP, acute pancreatitis; CC, acute cholecystitis; LOH, length of hospitalization.
FIGURE 2
FIGURE 2
Endoscopic retrograde cholangiopancreatography in pancreatitis patients with definite acute cholangitis. ERCP was performed in 89.3% of the patients. The table within the figure demonstrates the distribution of performance according to the time from hospital admission. The ERCP identified common bile duct stones in 41.3% of the cases. %, percentage; ABP, acute biliary pancreatitis; AC, acute cholangitis; CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; h, hours.
See this image and copyright information in PMC

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