Az epehólyag és az epeutak betegségei a leggyakrabban előforduló tápcsatornai kórképek közé tartoznak a fejlett országokban. Az epehólyag, illetve az epeutak heveny gyulladása potenciálisan súlyos, akár életet veszélyeztető állapot, melynek kezelése a kórkép azonnali felismerését és időben elkezdett multidiszciplináris ellátását igényli. Bár gyakori kórképekről van szó, az ellátás mégsem egységes hazai szinten. Az evidenciaalapú szakmai ajánlás célja a fenti kórképek diagnosztikus és súlyossági kritériumainak áttekintése, valamint a számos, rendelkezésre álló terápiás lehetőség indikációinak és alkalmazási szabályainak ismertetése. A jelen szakmai ajánlást a Magyar Gasztroenterológiai Társaság Endoszkópos Szekciójának vezetősége készítette a társszakmák jeles képviselőinek – sebész, infektológus, intervenciós radiológus – konszenzusa alapján, átlátható, a gyakorlatban hasznosítható fogódzót nyújtva a mindennapi betegellátás során. Ajánlásunk a japán vezető szakemberek által 2007-ben összeállított, majd nemzetközi szakértőkkel 2013-ban (TG13) és legutóbb 2018-ban (TG18) aktualizált Tokió-irányelveken alapul. Orv Hetil. 2023; 164(20): 770–787.
Kiriyama S, Takada T, Strasberg SM, et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2013; 20: 24–34.
Illés D, Urbán E, Lázár A, et al. Changes in antibiotic resistance in cholangitis. Our clinical experience. [Az antibiotikumrezisztencia változása cholangitisben. Klinikai tapasztalataink.] Orv Hetil. 2019; 160: 1437–1442. [Hungarian]
Kiriyama S, Kozaka K, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25: 17–30.
Xantus G, Peczelák P, Hegyi K, et al. Bedside ultrasound in adult primary care. [Ágy melletti ultrahangvizsgálat az alapellátásban.] Orv Hetil. 2022; 163: 2067–2071. [Hungarian]
Kiriyama S, Takada T, Hwang TL, et al. Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study. J Hepatobiliary Pancreat Sci. 2017; 24: 329–337.
Sun G, Han L, Yang Y, Linghu E, et al. Comparison of two editions of Tokyo guidelines for the management of acute cholangitis. J Hepatobiliary Pancreat Sci. 2014; 21: 113–119.
Schneider J, Hapfelmeier A, Thöres S, et al. Mortality risk for acute cholangitis (MAC): a risk prediction model for in-hospital mortality in patients with acute cholangitis. BMC Gastroenterol. 2016; 16: 15.
Hamano K, Noguchi O, Matsumoto Y, et al. Usefulness of procalcitonin for severity assessment in patients with acute cholangitis. Clin Lab. 2013; 59: 177–183.
Shinya S, Sasaki T, Yamashita Y, et al. Procalcitonin as a useful biomarker for determining the need to perform emergency biliary drainage in cases of acute cholangitis. J Hepatobiliary Pancreat Sci. 2014; 21: 777–785.
Miura F, Okamoto K, Takada T, et al. Tokyo guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018; 25: 31–40.
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021; 47: 1181–1247.
Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25: 3–16.
Miura F, Takada T, Strasberg SM, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20: 47–54.
American Society of Anesthesiologists. ASA Physical Status Classification System 2020. Available from: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system [accessed: 18 Ferbuary 2023].
Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40: 373–383.
Mayumi T, Okamoto K, Takada T et al. Tokyo guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25: 96–100.
Weber A, Schneider J, Wagenpfeil S, et al. Spectrum of pathogens in acute cholangitis in patients with and without biliary endoprosthesis. J Infect. 2013; 67: 111–121.
Salvador VB, Lozada MC, Consunji RJ. Microbiology and antibiotic susceptibility of organisms in bile cultures from patients with and without cholangitis at an Asian Academic Medical Center. Surg Infect. 2011; 12: 105–111.
Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020; 15: 61.
Gomi H, Takada T, Hwang TL, et al. Updated comprehensive epidemiology, microbiology, and outcomes among patients with acute cholangitis. J Hepatobiliary Pancreat Sci. 2017; 24: 310–318.
Péterfi Z. Antibiotics against the multiresistant bacteria. [Antibiotikumhasználat a multirezisztens baktériumok elleni küzdelemben.] Orvostovábbk Szle. 2019; 26: 42–44. [Hungarian]
Mukai S, Itoi T, Baron TH, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo guidelines 2018. J Hepatobiliary Pancreat Sci. 2017; 24: 537–549.
Tinusz B, Szapáry L, Paládi B, et al. Short-course antibiotic treatment is not inferior to a long-course one in acute cholangitis: a systematic review. Dig Dis Sci. 2019; 64: 307–315.
Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline – updated October 2017. Endoscopy 2018; 50: 910–930.
Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2020; 52: 127–149.
Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472–491.
Di Giorgio P, Manes G, Grimaldi E, et al. Endoscopic plastic stenting for bile duct stones: stent changing on demand or every 3 months. A prospective comparison study. Endoscopy 2013; 45: 1014–1017.
Takada T, Hanyu F, Kobayashi S, et al. Percutaneous transhepatic cholangial drainage: direct approach under fluoroscopic control. J Surg Oncol. 1976; 8: 83–97.
Saad WE, Wallace MJ, Wojak JC, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010; 21: 789–795.
Patel IJ, Davidson JC, Nikolic B, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 2012; 23: 727–736.
Hamada T, Yasunaga H, Nakai Y, et al. Severe bleeding after percutaneous transhepatic drainage of the biliary system: effect of antithrombotic agents-analysis of 34 606 cases from a Japanese nationwide administrative database. Radiology 2015; 274: 605–613.
Van der Merwe SW, van Wanrooij RL, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022; 54: 185–205.
Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis. Gastrointest Endosc. 2017; 85: 904–9014.
Sportes A, Camus M, Greget M, et al. Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers. Therap Adv Gastroenterol. 2017; 10: 483–493.
Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction. A multicenter randomized clinical trial. Am J Gastroenterol. 2018; 113: 987–997. Erratum: Am J Gastroenterol. 2018; 113: 1566.
Park JK, Woo YS, Noh DH, et al. Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study. Gastrointest Endosc. 2018; 88: 277–282.
Moryoussef F, Sportes A, Leblanc S, et al. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction? Therap Adv Gastroenterol. 2017; 10: 537–544.
Vanella G, Bronswijk M, Maleux G, et al. EUS-guided intrahepatic biliary drainage: a large retrospective series and subgroup comparison between percutaneous drainage in hilar stenoses or postsurgical anatomy. Endosc Int Open. 2020; 8: E1782–E1794.
Kongkam P, Orprayoon T, Boonmee C, et al. ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study. Endoscopy 2021; 53: 55–62.
Bill JG, Ryou M, Hathorn KE, et al. Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study. Surg Endosc. 2022; 36: 1362–1368.
Nennstiel S, Weber A, Frick G, et al. Drainage-related complications in percutaneous transhepatic biliary drainage: an analysis over 10 years. J Clin Gastroenterol. 2015; 49: 764–770.
Buxbaum JL, Buitrago C, Lee A, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021; 94: 207–221.e14.
Iqbal U, Khara HS, Hu Y, et al. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis. Gastrointest Endosc. 2020; 91: 753–760.e4.
Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Association between early ERCP and mortality in patients with acute cholangitis. Gastrointest Endosc. 2018; 87: 185–192.
Mulki R, Shah R, Qayed E. Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: a nationwide analysis. World J Gastrointest Endosc. 2019; 11: 41–53.
Karvellas CJ, Abraldes JG, Zepeda-Gomez S, et al. The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock. Aliment Pharmacol Ther. 2016; 44: 755–766.
Yokoe M, Hata J, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25: 41–54.
Kiewiet JJ, Leeuwenburgh MM, Bipat S, et al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012; 264: 708–720.
Fuks D, Mouly C, Robert B, et al. Acute cholecystitis: preoperative CT can help the surgeon consider conversion from laparoscopic to open cholecystectomy. Radiology 2012; 263: 128–138.
Oh KY, Gilfeather M, Kennedy A, et al. Limited abdominal MRI in the evaluation of acute right upper quadrant pain. Abdom Imaging. 2003; 28: 643–651.
Yokoe M, Takada T, Hwang TL, et al. Validation of TG13 severity grading in acute cholecystitis: Japan–Taiwan collaborative study for acute cholecystitis. J Hepatobiliary Pancreat Sci. 2017; 24: 338–345. Erratum: J Hepatobiliary Pancreat Sci. 2018; 25: 164.
Cheng WC, Chiu YC, Chuang CH, et al. Assessing clinical outcomes of patients with acute calculous cholecystitis in addition to the Tokyo grading: a retrospective study. Kaohsiung J Med Sci. 2014; 30: 459–465.
Endo I, Takada T, Hwang TL, et al. Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan–Taiwan multicenter cohort study. J Hepatobiliary Pancreat Sci. 2017; 24: 346–361. Erratum: J Hepatobiliary Pancreat Sci. 2017; 24: 492–493. Erratum: J Hepatobiliary Pancreat Sci. 2018; 25: 283–284.
Okamoto K, Suzuki K, Takada T, et al. Tokyo guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25: 55–72. Erratum: J Hepatobiliary Pancreat Sci. 2019; 26: 534.
Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013; 258: 385–393.
Borzellino G, Sauerland S, Minicozzi AM, et al. Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg Endosc. 2008; 22: 8–15.
Coccolini F, Catena F, Pisano M, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015; 18: 196–204. Erratum: Int J Surg. 2015; 24(Pt A): 107.
de Goede B, Klitsie PJ, Hagen SM, et al. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Br J Surg. 2013; 100: 209–216.
Loozen CS, van Santvoort HC, van Duijvendijk P, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ 2018; 363: k3965.
Ball E, Waters N, Cooper N, et al. Evidence-based guideline on laparoscopy in pregnancy: commissioned by the British Society for Gynaecological Endoscopy (BSGE) endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG). Facts Views Vis Obgyn. 2019; 11: 5–25. Erratum: Facts Views Vis Obgyn. 2020; 11: 261.
Shigemi D, Aso S, Matsui H, et al. Safety of laparoscopic surgery for benign diseases during pregnancy. A nationwide retrospective cohort study. J Minim Invasive Gynecol. 2019; 26: 501–506.
Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg. 2015; 150: 159–168.
Sabour AF, Matsushima K, Love, BE, et al. Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery 2020; 167: 569–574.
Mori Y, Itoi T, Baron TH, et al. Tokyo guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25: 87–95.
Itoi T, Takada T, Hwang TL, et al. Percutaneous and endoscopic gallbladder drainage for acute cholecystitis: international multicenter comparative study using propensity score-matched analysis. J Hepatobiliary Pancreat Sci. 2017; 24: 362–368.
Stanek A, Dohan A, Barkun J, et al. Percutaneous cholecystostomy: a simple bridge to surgery or an alternative option for the management of acute cholecystitis? Am J Surg. 2018; 216: 595–603.
Dimou FM, Adhikari D, Mehta HB, et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: a propensity score analysis. J Am Coll Surg. 2017; 224: 502–511.e1.
Barkay O, Bucksot L, Sherman S. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. Gastrointest Endosc. 2009; 70: 1039–1040.
Storm AC, Vargas EJ, Chin JY, et al. Transpapillary gallbladder stent placement for long-term therapy of acute cholecystitis. Gastrointest Endosc. 2021; 94: 742–748.e1.
Mohan BP, Khan SR, Trakroo S, et al. Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis. Endoscopy 2020; 52: 96–106.
Lee TH, Park DH, Lee SS, et al. Outcomes of endoscopic transpapillary gallbladder stenting for symptomatic gallbladder diseases: a multicenter prospective follow-up study. Endoscopy 2011; 43: 702–708.
Podboy A, Yuan J, Stave CD, et al. Comparison of EUS-guided endoscopic transpapillary and percutaneous gallbladder drainage for acute cholecystitis: a systematic review with network meta-analysis. Gastrointest Endosc. 2021; 93: 797–804.e1.
Sun X, Liu Y, Hu Q, et al. Endoscopic transpapillary gallbladder drainage for management of acute cholecystitis with coagulopathy. J Int Med Res. 2021; 49: 300060521996912.
Teoh AY, Kitano M, Itoi T, et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020; 69: 1085–1091.
Sobani ZA, Ling C, Rustagi T. Endoscopic ultrasound-guided gallbladder drainage. Dig Dis Sci. 2021; 66: 2154–2161.
Dollhopf M, Larghi A, Will U, et al. EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device. Gastrointest Endosc. 2017; 86: 636–643.
Imai H, Kitano M, Omoto S, et al. EUS-guided gallbladder drainage for rescue treatment of malignant distal biliary obstruction after unsuccessful ERCP. Gastrointest Endosc. 2016; 84: 147–151.
Chang JI, Dong E, Kwok KK. Endoscopic ultrasound-guided transmural gallbladder drainage in malignant obstruction using a novel lumen-apposing stent: a case series (with video). Endosc Int Open 2019; 7: E655– E661.