Acute cholangitis is a serious medical problem unless treated early. Although the diagnostic grading criteria on the 2018 Tokyo Guidelines (TG18) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice (2). Our study aims to apply and compare if the Tokyo 2018 guidelines can improve diagnostic accuracy and assist in earlier detection of acute cholangitis in an academic center in the United States.