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 http://www.jshbps.jp/en/guideline/tg13.html.