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Acute Cholangitis Management: Prevention of Organ Failure and Death.

The article by Schwed et al1 compared a more recent cohort of patients with acute cholangitis (AC) at 1 of the 2 institutions (validation cohort) with a historical group of similar patients (derivation cohort). Their prior study of the derivation cohort identified 3 independent admission risk factors that predisposed to adverse outcomes in AC: white blood cell (WBC) count greater than 20 000 cells/μL (to convert to ×109 per liter, multiply by 0.001), total bilirubin level greater than 10 mg/dL (to convert to micromoles per liter, multiply by 17.104), and advanced age.2 The aim of the current study was to validate the criteria previously identified. Treatment of AC has evolved with the availability of diagnostic modalities such as magnetic resonance cholangiography and endoscopic retrograde cholangiography. The Tokyo Guidelines from 2007 directed at making the diagnosis of AC were updated in 2013 (TG13), with improved sensitivity (87.6%) and specificity (77.7%).3 The criteria for diagnosis in TG13 are organized into 3 categories: systemic inflammation, cholestasis, and imaging findings. Additionally, TG13 provided a severity assessment grading system for AC: grade III (severe: signs of severe systemic infection and organ dysfunction), grade II (moderate: early signs of infection), and grade I (mild). Importantly, an abnormal WBC count is identified as greater than 12 000 cells/μL or less than 4000 cells/μL, and hyperbilirubinemia is determined at a total bilirubin level of 5 mg/dL or greater. The current report1 confirms risk factors the authors previously identified as predictors of poor outcome in AC with the outcome measures of death and/or organ failure. Somewhat surprisingly and contrary to traditional teaching, the authors found that a delay in timing of endoscopic retrograde cholangiography did not adversely affect outcomes even when factoring for severity of AC. The validation cohort had a statistically higher rate of severe cholangitis and endoscopic retrograde cholangiography performed within 24 hours of admission, but a shorter length of stay and lower rate of intensive care unit admission when compared with the derivation cohort. The WBC count and total bilirubin levels identified by the authors1 differ from those in TG13. In TG13, grade III severity AC is determined by the presence of signs of systemic failure and WBC count and total bilirubin level are not included. The authors1 have advocated addition of WBC count greater than 20 000 cells/μL and total bilirubin level greater than 10 mg/dL to TG13. These levels of WBC count and total bilirubin elevation would indicate more advanced AC and would be worthwhile additions to the grade III severity category, although it is not certain that this would achieve the ideal of identifying the potential for severe AC prior to organ dysfunction.