Diagnostic Criteria and Severity Grading of Acute Cholecystitis (TG18)

The diagnostic criteria for acute cholecystitis have high sensitivity (91.2%) and specificity (96.9%) and good diagnostic yield; therefore, their use as the diagnostic criteria for acute cholecystitis is recommended.

Diagnostic Criteria and Severity Grading of Acute Cholecystitis (TG18)

TG18/TG13 diagnostic criteria for acute cholecystitis

A. Local signs of inflammation

  1. Murphy’s sign,
  2. RUQ mass/pain/tenderness

B. Systemic signs of inflammation

  1. Fever
  2. Elevated CRP
  3. 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

The TG13 diagnostic criteria of acute cholecystitis was judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18 diagnostic criteria without any modification

Acute hepatitis, other acute abdominal diseases, and chronic chole-cystitis should be excluded

Abbreviations: CRP, C-reactive protein; RUQ, right upper abdominal quadrant; WBC, white blood cell.

 

TG18/TG13 severity grading for acute cholecystitis

Grade III (severe) acute cholecystitis. “Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:

  1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine
  2. Neurological dysfunction: decreased level of consciousness
  3. Respiratory dysfunction: PaO2/FiO2 ratio <300
  4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl
  5. Hepatic dysfunction: prothrombin ratio (PR) and international normalized ratio (INR) >1.5
  6. Hematological dysfunction: platelet count <100,000/mm3

Grade II (moderate) acute cholecystitis. “Grade II” acute cholecystitis is associated with any one of the following conditions:

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

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 asafe and low-risk operative procedure

 

The TG13 severity assessment criteria of acute cholecystitis was judged from numerous validation studies as use-ful indicators in clinical practice and adopted as TG18 severity assessment criteria without any modification. To judge predictive factors of acute cholecystitis on flowchart in Grade III, serum total bilirubin level is required to measure.

Laparoscopic surgery should be performed within 96 h of the onset of acute cholecystitis

 

 

References:

  1. Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, Kozaka K, Endo I, Deziel DJ, Miura F, Okamoto K, Hwang TL, Huang WS, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Noguchi Y, Shikata S, Ukai T, Higuchi R, Gabata T, Mori Y, Iwashita Y, Hibi T, Jagannath P, Jonas E, Liau KH, Dervenis C, Gouma DJ, Cherqui D, Belli G, Garden OJ, Giménez ME, de Santibañes E, Suzuki K, Umezawa A, Supe AN, Pitt HA, Singh H, Chan ACW, Lau WY, Teoh AYB, Honda G, Sugioka A, Asai K, Gomi H, Itoi T, Kiriyama S, Yoshida M, Mayumi T, Matsumura N, Tokumura H, Kitano S, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. [Medline]
  2. Gravito-Soares E, Gravito-Soares M, Gomes D, Almeida N, Tomé L. Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model. Scand J Gastroenterol. 2018 Mar;53(3):329-334. [Medline]

Created May 24, 2019.

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