Abdominal pain as an additional component of Tokyo Guidelines 2018 diagnostic criteria for acute cholangitis: Impact on diagnostic performance

Backgrounds/Aims:The Tokyo Guidelines 2018 (TG18), widely used for diagnosing acute cholangitis, comprise three components: (A) systemic inflammation, (B) cholestasis, and (C) imaging findings.Their diagnostic sensitivity is approximately 90%, and further improvement is desirable.Because abdominal pain is an important finding for differential diagnosis and may enhance sensitivity, we aimed to develop modified diagnostic criteria for acute cholangitis by incorporating abdominal pain into TG18 and to evaluate their diagnostic performance.Methods: The modified criteria added component D, defined as new-onset right upper quadrant or epigastric pain.Cases fulfilling all four components, any three of A-D, or A plus either B or C were regarded as cholangitis-positive.We retrospectively reviewed 266 patients admitted for suspected biliary inflammatory disease between January and June 2024.Results: The modified criteria showed significantly higher sensitivity than TG18 (99.5% vs. 90.2%,p < 0.001) but lower specificity (56.6% vs. 73.5%,p < 0.001).Diagnostic accuracy did not differ between the two criteria (86.1% vs. 85.0%,p = 0.719).Conclusions: Modified diagnostic criteria incorporating abdominal pain into TG18 achieved high sensitivity while maintaining diagnostic accuracy.