TG13 flowchart for the management of acute cholangitis and cholecystitis

Fumihiko Miura, Tadahiro Takada, Steven M. Strasberg, Joseph S. Solomkin, Henry A. Pitt, Dirk J. Gouma, O. James Garden, Markus W. Büchler, Masahiro Yoshida, Toshihiko Mayumi, Kohji Okamoto, Harumi Gomi, Shinya Kusachi, Seiki Kiriyama, Masamichi Yokoe, Yasutoshi Kimura, Ryota Higuchi, Yuichi Yamashita, John A. Windsor, Toshio TsuyuguchiToshifumi Gabata, Takao Itoi, Jiro Hata, Kui Hin Liau

Research output: Contribution to journalArticlepeer-review

164 Scopus citations


We propose a management strategy for acute cholangitis and cholecystitis according to the severity assessment. For Grade I (mild) acute cholangitis, initial medical treatment including the use of antimicrobial agents may be sufficient for most cases. For non-responders to initial medical treatment, biliary drainage should be considered. For Grade II (moderate) acute cholangitis, early biliary drainage should be performed along with the administration of antibiotics. For Grade III (severe) acute cholangitis, appropriate organ support is required. After hemodynamic stabilization has been achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. In patients with Grade II (moderate) and Grade III (severe) acute cholangitis, treatment for the underlying etiology including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has been improved. In patients with Grade I (mild) acute cholangitis, treatment for etiology such as endoscopic sphincterotomy for choledocholithiasis might be performed simultaneously, if possible, with biliary drainage. Early laparoscopic cholecystectomy is the first-line treatment in patients with Grade I (mild) acute cholecystitis while in patients with Grade II (moderate) acute cholecystitis, delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobial agent is the first-line treatment. In non-responders to initial medical treatment, gallbladder drainage should be considered. In patients with Grade III (severe) acute cholecystitis, appropriate organ support in addition to initial medical treatment is necessary. Urgent or early gallbladder drainage is recommended. Elective cholecystectomy can be performed after the improvement of the acute inflammatory process. Free full-text articles and a mobile application of TG13 are available via

Original languageEnglish (US)
Pages (from-to)47-54
Number of pages8
JournalJournal of Hepato-Biliary-Pancreatic Sciences
Issue number1
StatePublished - Jan 2013
Externally publishedYes


  • Acute cholangitis
  • Acute cholecystitis
  • Biliary drainage
  • Guidelines
  • Laparoscopic cholecystectomy

ASJC Scopus subject areas

  • Surgery
  • Hepatology


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