TG18/TG13 diagnostic criteria:

<aside> <img src="/icons/drafts_gray.svg" alt="/icons/drafts_gray.svg" width="40px" /> A. Local signs of inflammation:

Murphy's sign
RUQ mass/pain/tenderness

B. Systemic signs of inflammation:

Fever
Elevated CRP
Elevated WBC count

C. Imaging findings: Imaging findings characteristic of acute cholecystitis

Suspected diagnosis: One item in A + one item in B
Definite diagnosis: One item in A + one item in B + C </aside>

TG18/TG13 disease severity:

Grade I (mild) acute cholecystitis:

Grade I acute cholecystitis does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis.

It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure

Grade II (moderate) acute cholecystitis:

Associated with one of the following conditions:

Elevated WBC count (>18,000/mm3)
Palpable tender mass in the right upper abdominal quadrant
Duration of complaints >72 hours
Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade III (severe) acute cholecystitis:

Associated with dysfunction of any one of the following organs/systems:

Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine
Neurological dysfunction: decreased level of consciousness
Respiratory dysfunction: PaO2/FiO2 ratio <300
Renal dysfunction: oliguria, creatinine >2.0 mg/dl
Hepatic dysfunction: PT-INR >1.5
Hematological dysfunction: platelet count <100,000/mm3 </aside>

Management guidelines

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Grade I (mild) acute cholecystitis:

![TG18 flowchart for the management of acute cholecystitis Grade I. λ, CCI 5 or less and/or ASA class II or less (low risk); µ, CCI 6 or greater and/or ASA class III or greater (not low risk); ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status.

Okamoto, K., Suzuki, K., Takada, T., Strasberg, S.M., Asbun, H.J., Endo, I., Iwashita, Y., Hibi, T., Pitt, H.A., Umezawa, A., Asai, K., Han, H.-S., Hwang, T.-L., Mori, Y., Yoon, Y.-S., Huang, W.S.-W., Belli, G., Dervenis, C., Yokoe, M., Kiriyama, S., Itoi, T., Jagannath, P., Garden, O.J., Miura, F., Nakamura, M., Horiguchi, A., Wakabayashi, G., Cherqui, D., de Santibañes, E., Shikata, S., Noguchi, Y., Ukai, T., Higuchi, R., Wada, K., Honda, G., Supe, A.N., Yoshida, M., Mayumi, T., Gouma, D.J., Deziel, D.J., Liau, K.-H., Chen, M.-F., Shibao, K., Liu, K.-H., Su, C.-H., Chan, A.C.W., Yoon, D.-S., Choi, I.-S., Jonas, E., Chen, X.-P., Fan, S.T., Ker, C.-G., Giménez, M.E., Kitano, S., Inomata, M., Hirata, K., Inui, K., Sumiyama, Y. and Yamamoto, M. (2018), Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci, 25: 55-72. https://doi.org/10.1002/jhbp.516](https://s3-us-west-2.amazonaws.com/secure.notion-static.com/b3fe46ff-6f8c-4923-9df5-fd23399139de/TG_I.webp)

TG18 flowchart for the management of acute cholecystitis Grade I. λ, CCI 5 or less and/or ASA class II or less (low risk); µ, CCI 6 or greater and/or ASA class III or greater (not low risk); ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status.

Grade II (moderate) acute cholecystitis:

![TG18 flowchart for the management of acute cholecystitis Grade II. α, antibiotics and general supportive care successful; ϕ, antibiotics and general supportive care fail to control inflammation; λ, CCI 5 or less and/or ASA-PS class II or less (low risk); µ, CCI 6 or greater and/or ASA-PS class III or greater (not low risk); ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; †, a bile culture should be performed during GB drainage; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status, CCI Charlson comorbidity index, GB gallbladder, LC laparoscopic cholecystectomy.

TG18 flowchart for the management of acute cholecystitis Grade II. α, antibiotics and general supportive care successful; ϕ, antibiotics and general supportive care fail to control inflammation; λ, CCI 5 or less and/or ASA-PS class II or less (low risk); µ, CCI 6 or greater and/or ASA-PS class III or greater (not low risk); ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; †, a bile culture should be performed during GB drainage; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status, CCI Charlson comorbidity index, GB gallbladder, LC laparoscopic cholecystectomy.

Grade III (severe) acute cholecystitis:

![TG18 flowchart for the management of acute cholecystitis Grade III. ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; #, negative predictive factors: jaundice (TBil ≥2), neurological dysfunction, respiratory dysfunction; Φ, FOSF: favorable organ system failure = cardiovascular or renal organ system failure which is rapidly reversible after admission and before early LC in AC; *, in cases of Grade III, CCI (Charlson comorbidity index) 4 or greater, ASA-PS 3 or greater are high risk; †, a bile culture should be performed during GB drainage; Ψ, advanced center = intensive care and advanced laparoscopic techniques are available; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. GB gallbladder, LC laparoscopic cholecystectomy, PS performance status

TG18 flowchart for the management of acute cholecystitis Grade III. ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; #, negative predictive factors: jaundice (TBil ≥2), neurological dysfunction, respiratory dysfunction; Φ, FOSF: favorable organ system failure = cardiovascular or renal organ system failure which is rapidly reversible after admission and before early LC in AC; *, in cases of Grade III, CCI (Charlson comorbidity index) 4 or greater, ASA-PS 3 or greater are high risk; †, a bile culture should be performed during GB drainage; Ψ, advanced center = intensive care and advanced laparoscopic techniques are available; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. GB gallbladder, LC laparoscopic cholecystectomy, PS performance status

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Transfer criteria for acute cholecystitis

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Mild acute cholecystitis (Grade I)

In the case of patients whose operation is delayed because of existing serious comorbidity transfer to advanced facilities that can provide emergent drainage of the gallbladder or early Lap-C should be considered

Moderate acute cholecystitis (Grade II)

Patients should be treated at centers that can provide emergent drainage of the gallbladder or early Lap-C. Otherwise, transfer to advanced facilities should be considered

Severe acute cholecystitis (Grade III)

When a patient meets certain conditions defined by the AC flowchart, Lap-C can be performed only by an expert laparoscopic surgeon at a specialized center that provides intensive care. Otherwise, transfer to advanced facilities should be considered

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