Home - News ( United States | United Kingdom | Italy | Germany ) - Football scores

Showing content from https://link.springer.com/doi/10.1007/s00534-006-1153-x below:

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient’s general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient’s general medical condition.

Acute biliary inflammation/infection is classified as either acute cholangitis or acute cholecystitis, and ranges from mild forms that improve with medical treatment to severe forms that require intensive care and urgent intervention. The medical condition of a patient with biliary inflammation/infection is likely to deteriorate rapidly and the condition can become life-threatening. Early diagnosis should be made based on clinical signs/symptoms and laboratory findings. The type and timing of treatment should be based on the grade of severity of the disease.

Although endoscopic and laparoscopic techniques have advanced recently (level 1b–2b),1,2 the treatment of severe acute biliary inflammation/infection still results in fatalities and increased hospital costs. To our knowledge, there are no definite diagnostic and therapeutic guidelines for acute biliary inflammation/infection according to the grade of severity of the disease. This article describes the management strategy for biliary inflammation/infection in accordance with the severity of the biliary disease. Guidelines were developed, based on best clinical evidence and discussions at the International Consensus Meeting held in Tokyo on April 1–2, 2006.

A flowchart showing general guidance for the management of acute biliary inflammation/infection is presented in Fig. 1.

Flowchart showing general guidance for the management of acute biliary infection

Clinical findings associated with acute cholangitis include abdominal pain, jaundice, fever (Charcot’s triad), and rigor. The triad was already reported as an indicator of hepatic fever by Charcot in 1877,3 and has been, historically, used as the generally accepted clinical findings of acute cholangitis. About 50%–70% of patients with acute cholangitis develop all three symptoms (level 2b-4).4–7 Reynolds’ pentad (Charcot’s triad plus shock and a decreased level of consciousness) was presented in 1959, when Reynolds and Dargan8 defined acute obstructive cholangitis. The pentad is often used to indicate severe (grade III) cholangitis, but shock and a decreased level of consciousness are observed in only 30% or fewer patients with acute cholangitis (level 2b-4).4–7 A history of biliary disease, such as gallstones, previous biliary procedures, or the placement of a biliary stent are factors that are very helpful to suggest a diagnosis of acute cholangitis.

Clinical symptoms of acute cholecystitis include abdominal pain (right upper abdominal pain), nausea, vomiting, and fever (level 2b-4).9–11 The most typical symptom is right epigastric pain. Tenderness in the right upper abdomen, a palpable gallbladder, and Murphy’s sign are the characteristic findings of acute cholecystitis. A positive Murphy’s sign has a specificity of 79%–96% (level 2b–3b)9,11 for acute cholecystitis.

The diagnosis of acute cholangitis requires a white blood cell count; measurement of the C-reactive protein level; and liver function tests, including alkaline phosphatase, gamma-glutamyltranspeptidase (GGT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. Assessment of the severity of the illness requires knowledge of the platelet count, blood urea nitrogen, creatinine, and prothrombin time (PT). Blood cultures are also helpful for severity assessment, as well as for the selection of antimicrobial drugs. Hyperamylasemia is a useful parameter to identify complications such as choledocholithiasis causing biliary pancreatitis (level 1a).12

There is no specific blood test for acute cholecystitis; however, the white blood cell count and the measurement of C-reactive protein is very useful in confirming an inflammatory process. Bilirubin, blood urea nitrogen, creatinine, and PT are very useful in assessing the disease severity status of the patient.

Abdominal ultrasound (US) and abdominal computerized tomography (CT) with intravenous contrast are very helpful studies in evaluating patients with acute biliary tract disease. Abdominal US should be performed in all patients suspected of having acute biliary inflammation/infection. Ultrasound examination has satisfactory diagnostic capability when it is performed not only by specialists but also by emergency physicians (level 1b).13,14

The role of diagnostic imaging in acute cholangitis is to determine the presence/absence of biliary obstruction, the level of the obstruction, and the cause of the obstruction, such as gallstones and/or biliary strictures. Assessment should include both US and CT. These studies complement each other and CT may better demonstrate dilatation of the bile duct and pneumobilia.

Some of the characteristic finding of acute cholecystitis include an enlarged gallbladder, thickened gallbladder wall, gallbladder stones and/or debris in the gallbladder, sonographic Murphy’s sign, pericholecystic fluid, and pericholecystic abscess. Sonographic Murphy’s sign is a very reliable finding of acute cholecystitis, with a specificity exceeding 90% (level 3b,4).15,16 CT scan or even plain X-ray may demonstrate free air, pneumobilia, and ileus.

Diseases which should be differentiated from acute cholangitis are acute cholecystitis, gastric and duodenal ulcer, acute pancreatitis, acute hepatitis, and septicemia of other origins. Diseases which should be differentiated from acute cholecystitis are gastric and duodenal ulcer, hepatitis, pancreatitis, gallbladder cancer, hepatic abscess, Fitz-Hugh-Curtis syndrome, right lower lobar pneumonia, angina pectoris, myocardial infarction, and urinary infection.

A flowchart for the management of acute cholangitis is shown in Fig. 2. The treatment of acute cholangitis should be guided by the grade of severity of the disease. Biliary drainage and antibiotics are the two most important elements of treatment. When a diagnosis of acute cholangitis is suspected, medical treatment, including nil per os (NPO) and the use of intravenous fluids, antibiotics, and analgesia, together with close monitoring of blood pressure, pulse, and urinary output should be initiated. Simultaneously, a severity assessment of the cholangitis should be documented, even if it is mild. Frequent reassessment is important, and patients may need to be reclassified as having mild (grade I), moderate (grade II), or severe (grade III) disease, based on the response to medical treatment. Appropriate treatment should be performed in accordance with the severity grade. Patients with concomitant diseases such as acute pancreatitis or malignant tumor, and elderly patients are likely to progress to a severe level; therefore, such patients should be monitored frequently.

Flowchart for the management of acute cholangitis

Medical treatment may be sufficient. Biliary drainage is not required in most cases. However, for nonresponders to medical treatment, the necessity of biliary drainage should be considered. Treatment options such as endoscopic, percutaneous, or operative intervention may be required, depending on the etiology. Some patients, such as those who develop postoperative cholangitis, may only require antibiotics and generally do not require intervention.

Patients with acute cholangitis who do not respond to medical treatment have moderate (grade II) acute cholangitis. In these patients, early endoscopic or percutaneous drainage or even emergent operative drainage with a T-tube should be performed. A definitive procedure should be performed to remove the cause of the obstruction once the patient is in a stable condition.

Patients with acute cholangitis and organ failure are classified as having severe (grade III) acute cholangitis. These patients require organ support, such as ventilatory/circulatory management (e.g., endotracheal intubation, artificial respiration management, and the use of vasopressin), and treatment for disseminated intravascular coagulation (DIC) in addition to the general medical management. Urgent biliary drainage must be anticipated. When the patient is stabilized, urgent (ASAP) endoscopic or percutaneous transhepatic biliary drainage or an emergent operation with decompression of the bile duct with a T-tube should be performed. Definitive treatment of the cause of the obstruction, including endoscopic, percutaneous, or operative intervention, should be considered once the acute illness has resolved.

At the International Consensus Meeting, responses to the flowcharts for the management of the different grades of acute cholangitis were elicited and a consensus was reached (Fig. 3).

A Responses to the question “Do you agree with the flowchart for the management of mild acute (grade I) cholangitis?” The flowchart for the management of mild acute (grade I) cholangitis was agreed upon by 100% and 97% of the panelists and the audience, respectively. B Responses to the question “Do you agree with the flowchart for the management of moderate acute (grade II) cholangitis?” The flowchart for the management of moderate acute (grade II) cholangitis was agreed upon by 93% and 97% of the panelists and the audience, respectively. C Responses to the question “Do you agree with the flowchart for the management of severe acute (grade III) cholangitis?” The flowchart for the management of severe acute (grade III) cholangitis was agreed upon by 98% and 99% of the panelists and the audience, respectively

A flowchart for the management of acute cholecystitis is shown in Fig. 4. Early cholecystectomy is recommended for most patients, with laparoscopic cholecystectomy as the preferred method. Among high-risk patients, percutaneous gallbladder drainage is an alternative therapy for those patients who cannot safely undergo urgent/early cholecystectomy (level 4).17,18

Flowchart for the management of acute cholecystitis. GB, gallbladder; LC, laparoscopic cholecystectomy

When a diagnosis of acute cholecystitis is suspected, medical treatment, including NPO, intravenous fluids, antibiotics, and analgesia, together with close monitoring of blood pressure, pulse, and urinary output should be initiated. Simultaneously, the grade of severity needs to be established. Appropriate treatment should be performed in accordance with the severity grade. The assessment of operative risk should also be evaluated based on the severity grade.

After the acute inflammation has been resolved by medical treatment and gallbladder drainage, it is desirable to perform a cholecystectomy to prevent recurrence. In surgically high-risk patients with cholecystolithasis, medical support after percutaneous cholecystolithotomy should be considered (level 4).19–21 For patients with acalculous cholecystitis, cholecystectomy is not required, because recurrence of acute acalculous cholecystitis after gallbladder drainage is rare (level 4).17,22

Early laparoscopic cholecystectomy is the preferred treatment. Elective cholecystectomy may be selected (if early cholecystectomy is not performed) in order to improve other medical problems.

Early laparoscopic or open cholecystectomy is preferred. If a patient has serious local inflammation making early cholecystectomy difficult, then percutaneous or operative drainage of the gallbladder is recommended. Elective cholecystectomy can be performed after improvement of the acute inflammatory process.

Severe (grade III) acute cholecystitis is accompanied by organ dysfunction and/or severe local inflammation. Appropriate organ support in addition to medical treatment is necessary for patients with organ dysfunction. Management of severe local inflammation by percutaneous gallbladder drainage and/or cholecystectomy is needed. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and drainage. Elective cholecystectomy may be performed after improvement of the acute illness by gallbladder drainage.

At the International Consensus Meeting, flowcharts for the management of mild (grade I) and severe (grade III) acute cholecystitis were agreed upon by almost all of the participants; however, the flowchart for moderate (grade II) acute cholecystitis was agreed upon by fewer than 90% of the participants (Fig. 5).

A Responses to the question “Do you agree with the flowchart for the management of mild acute (grade I) cholecystitis?” The flowchart for the management of mild acute (grade I) cholecystitis was agreed upon by 92% and 87% of the panelists and the audience, respectively. B Responses to the question “Do you agree with the flowchart for the management of moderate acute (grade II) cholecystitis?” The flowchart for the management of moderate acute (grade II) cholecystitis was agreed upon by 89% and 83% of the Japanese panelists and the Japanese audience, respectively. C Responses to the question “Do you agree with the flowchart for the management of severe acute (grade III) cholecystitis?” The flowchart for the management of severe acute (grade III) cholecystitis was agreed upon by 97% and 95% of the panelists and audience, respectively

1. EC Lai FP Mok ES Tan CM Lo ST Fan KT You et al. (1992) ArticleTitleEndoscopic biliary drainage for severe acute cholangitis N Engl J Med 326 1582–6 Occurrence Handle1:STN:280:DyaK383mtFKktQ%3D%3D Occurrence Handle1584258 Occurrence Handle10.1056/NEJM199206113262401

   Article  CAS  PubMed  Google Scholar 

2. CM Lo CL Liu ST Fan EC Lai J Wong (1998) ArticleTitleProspective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis Ann Surg 227 461–7 10.1097/00000658-199804000-00001 Occurrence Handle10.1097/00000658-199804000-00001 Occurrence Handle1:STN:280:DyaK1c3it12qsQ%3D%3D Occurrence Handle9563529

   Article  CAS  PubMed  Google Scholar 

3. M Charcot (1877) De la fievre hepatique symptomatique Comparison avec la fievre uroseptique Bourneville et Sevestre Paris

   Google Scholar 

4. JH Boey LW Way (1980) ArticleTitleAcute cholangitis Ann Surg 191 264–70 10.1097/00000658-198003000-00002 Occurrence Handle10.1097/00000658-198003000-00002 Occurrence Handle1:STN:280:DyaL3c7lt1eqsQ%3D%3D Occurrence Handle7362292

   Article  CAS  PubMed  Google Scholar 

5. A Csendes JC Diaz P Burdiles F Maluenda E Morales (1992) ArticleTitleRisk factors and classification of acute suppurative cholangitis Br J Surg 79 655–8 Occurrence Handle10.1002/bjs.1800790720 Occurrence Handle1:STN:280:DyaK38zltlOqtQ%3D%3D Occurrence Handle1643478

   Article  CAS  PubMed  Google Scholar 

6. JP Welch GA Donaldson (1976) ArticleTitleThe urgency of diagnosis and surgical treatment of acute suppurative cholangitis Am J Surg 131 527–32 10.1016/0002-9610(76)90003-9 Occurrence Handle10.1016/0002-9610(76)90003-9 Occurrence Handle1:STN:280:DyaE283gtlKnug%3D%3D Occurrence Handle1275137

   Article  CAS  PubMed  Google Scholar 

7. MJ O’Connor ML Schwartz DG McQuarrie HW Sumer (1982) ArticleTitleAcute bacterial cholangitis: an analysis of clinical manifestation Arch Surg 117 437–41 Occurrence Handle7065890

   PubMed  Google Scholar 

8. BM Reynolds EL Dargan (1959) ArticleTitleAcute obstructive cholangitis; a distinct clinical syndrome Ann Surg 150 299–303 10.1097/00000658-195908000-00013 Occurrence Handle10.1097/00000658-195908000-00013 Occurrence Handle1:STN:280:DyaG1M7gtVensw%3D%3D Occurrence Handle13670595

   Article  CAS  PubMed  Google Scholar 

9. M Eskelinen J Ikonen P Lipponen (1993) ArticleTitleDiagnostic approaches in acute cholecystitis; a prospective study of 1333 patients with acute abdominal pain Theor Surg 8 15–20

   Google Scholar 

10. JR Staniland J Ditchburn FT De Dombal (1972) ArticleTitleClinical presentation of acute abdomen: study of 600 patients BMJ 3 393–8 10.1136/bmj.3.5823.393 Occurrence Handle10.1136/bmj.3.5823.393 Occurrence Handle1:STN:280:DyaE3s%2FgtlaitQ%3D%3D Occurrence Handle4506871

    Article  CAS  PubMed  Google Scholar 

11. RL Trowbridge NK Rutkowski KG Shojania (2003) ArticleTitleDoes this patient have acute cholecystitis? JAMA 289 80–6 10.1001/jama.289.1.80 Occurrence Handle10.1001/jama.289.1.80 Occurrence Handle12503981

    Article  PubMed  Google Scholar 

12. PA Abboud PF Malet JA Berlin R Staroscik MD Cabana JR Clarke et al. (1996) ArticleTitlePredictors of common bile duct stones prior to cholecystectomy: a meta-analysis Gastrointest Endosc 44 450–5 10.1016/S0016-5107(96)70098-6 Occurrence Handle10.1016/S0016-5107(96)70098-6 Occurrence Handle1:STN:280:DyaK2s%2FmtFegtQ%3D%3D Occurrence Handle8905367

    Article  CAS  PubMed  Google Scholar 

13. CL Rosen DF Brown Y Chang C Moore NJ Averill LJ Arkoff et al. (2001) ArticleTitleUltrasonography by emergency physicians in patients with suspected cholecystitis Am J Emerg Med 19 32–6 10.1053/ajem.2001.20028 Occurrence Handle10.1053/ajem.2001.20028 Occurrence Handle1:STN:280:DC%2BD3M7nsleluw%3D%3D Occurrence Handle11146014

    Article  CAS  PubMed  Google Scholar 

14. JL Kendall RJ Shimp (2001) ArticleTitlePerformance and interpretation of focused right upper quadrant ultrasound by emergency physicians J Emerg Med 21 7–13 10.1016/S0736-4679(01)00329-8 Occurrence Handle10.1016/S0736-4679(01)00329-8 Occurrence Handle1:STN:280:DC%2BD3Mzjt1Snug%3D%3D Occurrence Handle11399381

    Article  CAS  PubMed  Google Scholar 

15. PW Ralls J Halls SA Lapin MF Quinn UL Morris W Boswell (1982) ArticleTitleProspective evaluation of the sonographic Murphy sign in suspected acute cholecystitis J Clin Ultrasound 10 113–5 Occurrence Handle10.1002/jcu.1870100305 Occurrence Handle1:STN:280:DyaL387ptVCgtg%3D%3D Occurrence Handle6804512

    Article  CAS  PubMed  Google Scholar 

16. P Soyer JP Brouland M Boudiaf M Kardache JP Pelage Y Panis et al. (1998) ArticleTitleColor velocity imaging and power Doppler sonography of the gallbladder wall: a new look at sonographic diagnosis of acute cholecystitis Am J Roentgenol AJR 171 183–8 Occurrence Handle1:STN:280:DyaK1czhtFWiuw%3D%3D

    CAS  Google Scholar 

17. M Sugiyama M Tokuhara Y Atomi (1998) ArticleTitleIs percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 22 459–63 10.1007/s002689900416 Occurrence Handle10.1007/s002689900416 Occurrence Handle1:STN:280:DyaK1c3isFCnuw%3D%3D Occurrence Handle9564288

    Article  CAS  PubMed  Google Scholar 

18. S Chopra GD Dodd Suffix3rd AL Mumbower KN Chintapalli WH Schwesinger KR Sirinek et al. (2001) ArticleTitleTreatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystostomy Am J Roentgenol AJR 176 1025–31 Occurrence Handle1:STN:280:DC%2BD3M7msF2guw%3D%3D

    CAS  Google Scholar 

19. K Inui S Nakazawa Y Naito E Kimoto K Yamao (1988) ArticleTitleNonsurgical treatment of cholecystolithiasis with percutaneous transhepatic cholecystoscopy Am J Gastroenterol 83 1124–7 Occurrence Handle1:STN:280:DyaL1czjvVGlug%3D%3D Occurrence Handle3421223

    CAS  PubMed  Google Scholar 

20. GW Boland MJ Lee PR Mueller SL Dawson J Gaa DS Lu et al. (1994) ArticleTitleGallstones in critically ill patients with acute calculous cholecystitis treated by percutaneous cholecystostomy: nonsurgical therapeutic options Am J Roentgenol AJR 162 1101–3 Occurrence Handle1:STN:280:DyaK2c3hvFejtQ%3D%3D

    CAS  Google Scholar 

21. AW Majeed MW Reed B Ross J Peacock AG Johnson (1997) ArticleTitleGallstone removal with a modified cholecystoscope: an alternative to cholecystectomy in the high-risk patient J Am Coll Surg 184 273–80 Occurrence Handle1:STN:280:DyaK2s3hsVGntw%3D%3D Occurrence Handle9060925

    CAS  PubMed  Google Scholar 

22. Y Shirai K Tsukada H Kawaguchi T Ohtani T Muto K Hatakeyama (1993) ArticleTitlePercutaneous transhepatic cholecystostomy for acute acalculous cholecystitis Br J Surg 80 1440–2 Occurrence Handle10.1002/bjs.1800801129 Occurrence Handle1:STN:280:DyaK2c%2FntlKltg%3D%3D Occurrence Handle8252358

    Article  CAS  PubMed  Google Scholar 

Download references

We would like to express our deep gratitude to the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary-Pancreatic Surgery, who provided us with great support and guidance in the preparation of the Guidelines. This process was conducted as part of the project for the Preparation and Diffusion of Guidelines for the Management of Acute Cholangitis (H-15-Medicine-30), with a research subsidy for fiscal 2003 and 2004 (Integrated Research Project for Assessing Medical Technology), sponsored by the Japanese Ministry of Health, Labour, and Welfare.

We also truly appreciate the panelists who cooperated with and contributed significantly to the International Consensus Meeting held in Tokyo on April 1 and 2, 2006.

1. Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605, Japan

   Fumihiko Miura, Tadahiro Takada, Keita Wada & Masahiro Yoshida

2. Mie University School of Medicine, Mie, Japan

   Yoshifumi Kawarada

3. Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

   Yuji Nimura & Masato Nagino

4. Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan

   Masahiko Hirota

5. Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan

   Toshio Tsuyuguchi

6. Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine, Nagoya, Japan

   Toshihiko Mayumi

7. Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital, St Louis, USA

   Steven M. Strasberg

8. Department of Surgery, Indiana University School of Medicine, Indianapolis, USA

   Henry A. Pitt

9. Department of Digestive Surgery and Transplantation, Hospital Beaujon, Clichy, France

   Jacques Belghiti

10. Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina

    Eduardo de Santibanes

11. Department of Gastrointestinal Surgery, Medical College of Georgia, Georgia, USA

    Thomas R. Gadacz

12. Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

    Dirk J. Gouma

13. Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China

    Sheung-Tat Fan

14. Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan

    Miin-Fu Chen

15. Division of Surgical and Specialty Services, Flinders Medical Centre, Adelaide, Australia

    Robert T. Padbury

16. Division of General Surgery, University of Cape Town, Cape Town, South Africa

    Philippus C. Bornman

17. Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

    Sun-Whe Kim

18. Department of Surgery, Tan Tock Seng Hospital / Hepatobiliary Surgery, Medical Centre, Singapore, Singapore

    Kui-Hin Liau

19. Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Naples, Italy

    Giulio Belli

20. First Department of Surgery, Agia Olga Hospital, Athens, Greece

    Christos Dervenis

1. Fumihiko Miura
2. Tadahiro Takada
3. Yoshifumi Kawarada
4. Yuji Nimura
5. Keita Wada
6. Masahiko Hirota
7. Masato Nagino
8. Toshio Tsuyuguchi
9. Toshihiko Mayumi
10. Masahiro Yoshida
11. Steven M. Strasberg
12. Henry A. Pitt
13. Jacques Belghiti
14. Eduardo de Santibanes
15. Thomas R. Gadacz
16. Dirk J. Gouma
17. Sheung-Tat Fan
18. Miin-Fu Chen
19. Robert T. Padbury
20. Philippus C. Bornman
21. Sun-Whe Kim
22. Kui-Hin Liau
23. Giulio Belli
24. Christos Dervenis

Miura, F., Takada, T., Kawarada, Y. et al. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14, 27–34 (2007). https://doi.org/10.1007/s00534-006-1153-x

Download citation

• Received: 31 May 2006

• Accepted: 06 August 2006

• Published: 30 January 2007

• Issue Date: January 2007

• DOI: https://doi.org/10.1007/s00534-006-1153-x

RetroSearch is an open source project built by @garambo | Open a GitHub Issue

Search and Browse the WWW like it's 1997 | Search results from DuckDuckGo

HTML: 3.2 | Encoding: UTF-8 | Version: 0.7.4