Acute cholangitis is a common diagnostic and therapeutic emergency resulting from biliary tract infection, most often secondary to obstruction. The Tokyo Guidelines 2018 (TG18) were established to provide standardized recommendations for the diagnosis, treatment, and management of acute cholangitis. However, few studies have assessed the extent to which these guidelines are implemented in real-world clinical practice.The aim of this study was to conduct a retrospective evaluation of the management of acute cholangitis by comparing therapeutic approaches with the recommendations of the Tokyo Guidelines 2018.

This retrospective descriptive study was conducted in the Department of Hepato-Gastroenterology and Proctology. The study included all patients diagnosed with acute cholangitis between 2021 and 2025. Diagnostic criteria were based on three components: signs of inflammation, cholestasis, and imaging findings .Collected data included demographic characteristics (age, sex), clinical presentation, laboratory results, and both medical and endoscopic therapeutic interventions.Compliance with the guidelines was assessed based on diagnostic criteria, time to biliary drainage, antibiotic adaptation, and the use of drainage techniques.

A total of 160 cases of acute cholangitis were recorded. The mean age of the patients was 63 years (range: 17–88), with a predominance of males (M/F ratio 1.25).Diagnosis was established according to the Tokyo criteria: among the 160 patients, 142 (89%) presented with systemic inflammatory signs, including fever and/or chills. All patients (100%) had biological evidence of infection and cholestasis, with a mean CRP of 114.50 mg/L, a mean white blood cell count of 14,084/mm³, and a mean total bilirubin level of 101 mg/L.Etiologies were distributed as follows: lithiasis in 98 patients (61.25%), neoplastic obstruction in 55 patients (34.38%), and other causes including ruptured hydatid cyst or ampullary tumors in 7 patients (4.38%).Severity assessment showed that 38 patients (23.75%) had grade I cholangitis, 72 patients (45%) grade II, and 50 patients (31.25%) grade III according to the Tokyo Guidelines classification.

Therapeutic management consisted of early biliary drainage and systemic antibiotic therapy. Broad-spectrum intravenous antibiotics, including third-generation cephalosporins and metronidazole, were administered to 158 patients (98.75%) upon admission. Antibiotic regimens were adjusted in 90 patients (56%) based on blood or bile culture results.Endoscopic management was performed as the first-line treatment in 156 patients (97.5%). Two patients (1.25%) required surgical intervention, and none required radiologic drainage.

Regarding compliance with drainage timing: among the 50 grade III patients, 27 (54%) underwent biliary decompression within the recommended 24 hours. For grade II patients, 43 (60%) received drainage within 72 hours, and 21 grade I patients (56%) underwent drainage within the same timeframe.The rate of early complications following endoscopic intervention was 12.5% (n = 20), including recurrent infections and post-Endoscopic Retrograde Cholangiopancreatography pancreatitis. Complications correlated with the severity of cholangitis: patients with grade III disease exhibited the highest complication rate (20%, n = 10), followed by grade II (11%, n = 8), while grade I patients had a complication rate of 5.3% (n = 2).

Acute cholangitis remains a severe condition requiring rapid management in accordance with the Tokyo Guidelines. Strict adherence to these recommendations is essential to optimize clinical outcomes, reduce complications, and improve patient survival. Continuous updating of institutional protocols and strengthened monitoring of guideline compliance are necessary to ensure optimal management of acute cholangitis.