Toward an evidence-based approach for cholangitis diagnosis

Despite improvements in imaging and laboratory medicine, consensus criteria for the diagnosis of cholangitis are lacking. Although ERCP is an effective treatment for cholangitis, it should be reserved for those patients with a high probability of the diagnosis, given the morbidity associated with the procedure.

A comprehensive literature search of PubMed (from 1898 to present), Web of Science (1900 to July 15, 2019), Embase (1943 to July 15, 2019), and the Cochrane library (1898 to July 15, 2019) was performed to identify studies that reported on diagnostic paradigms and individual diagnostic parameters of cholangitis. This was used to identify domains associated with high probability of cholangitis.

We identified 23 observational studies (10,252 patients) that evaluated the performance of individual and combined criteria for the diagnosis of cholangitis. Traditional paradigms including Charcot's criteria and Ranson's criteria have inadequate sensitivity, and complexity has limited the implementation of the contemporary Tokyo criteria. Furthermore, controlled studies to validate diagnostic criteria for cholangitis are lacking. Existing literature suggests that 4 criteria, summarized by the acronym BILE, identifies those at high risk of cholangitis: Biliary imaging abnormalities or recent intervention, Inflammatory test abnormalities, Liver test abnormalities, and Exclusion of cholecystitis and acute pancreatitis.

There is a need for cholangitis diagnostic criteria that are supported by controlled validation studies, consistent with contemporary clinical values, and amenable to implementation. The BILE criteria are straightforward but require prospective study of their diagnostic performance and ability to avert unnecessary ERCP.