There is a noteworthy overlap between the clinical picture of biliary acute pancreatitis
(AP) and the 2018 Tokyo guidelines currently used for the diagnosis of cholangitis
(AC) and cholecystitis (CC). This can lead to significant antibiotic and endoscopic
retrograde cholangiopancreatography (ERCP) overuse.We aimed to assess the on-admission
prevalence of AC/CC according to the 2018 Tokyo guidelines (TG18) in a cohort of biliary
AP patients, and its association with antibiotic use, ERCP and clinically relevant
endpoints.We conducted a secondary analysis of the Hungarian Pancreatic Study Group's
prospective multicenter registry of 2195 AP cases. We grouped and compared biliary
cases (n = 944) based on the on-admission fulfillment of definite AC/CC according
to TG18. Aside from antibiotic use, we evaluated mortality, AC/CC/AP severity, ERCP
performance and length of hospitalization. We also conducted a literature review discussing
each criteria of the TG18 in the context of AP.27.8% of biliary AP cases fulfilled
TG18 for both AC and CC, 22.5% for CC only and 20.8% for AC only. Antibiotic use was
high (77.4%). About 2/3 of the AC/CC cases were mild, around 10% severe. Mortality
was below 1% in mild and moderate AC/CC patients, but considerably higher in severe
cases (12.8% and 21.2% in AC and CC). ERCP was performed in 89.3% of AC cases, common
bile duct stones were found in 41.1%.Around 70% of biliary AP patients fulfilled the
TG18 for AC/CC, associated with a high rate of antibiotic use. Mortality in presumed
mild or moderate AC/CC is low. Each of the laboratory and clinical criteria are commonly
fulfilled in biliary AP, single imaging findings are also unspecific-AP specific diagnostic
criteria are needed, as the prevalence of AC/CC are likely greatly overestimated.
Randomized trials testing antibiotic use are also warranted.
