Unifying Concepts

Diagnosis and Determination of Severity of Acute Cholecystitis

Acute cholecystitis is a very common complication of cholelithiasis, and as such is frequently encountered in surgical practice. TG07 diagnostic criteria are recognized as those to be recommended in current care for acute cholecystitis.

Guidelines for the Diagnosis and Determination of Severity of Acute Cholecystitis

Diagnostic Criteria
Local signs of inflammation

  • Murphy’s sign
  • Mass, pain, or tenderness in right upper quadrant

Systemic signs of inflammation

  • Fever
  • Elevated levels of C-reactive protein
  • Leukocytosis

Findings on imaging characteristic of acute cholecystitis

  • Gallbladder-wall thickness >/=5 mm, pericholecystic fluid, or direct tenderness when probe is pushed against gallbladder (i.e., ultrasonographic Murphy’s sign)


  • Positivity for one item in local signs of inflammation and one item in systemic signs of inflammation


  • Positivity for one item in local signs of inflammation, one item in systemic signs of inflammation, and findings on imaging characteristic of acute cholecystitis

Disease severity
Grade I (mild)

  • Acute cholecystitis in otherwise healthy patient with mild local inflammatory changes and without organ dysfunction
  • Criteria for grade II or III not met

Grade II (moderate): any one of the following characteristics

  • Leukocytosis (>18,000 cells per mm3)
  • Palpable, tender mass in right upper quadrant
  • Symptom duration >72 hr
  • Marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis

Grade III (severe): organ dysfunction in any one of the following systems

  • Cardiovascular: Hypotension requiring administration of >/= 5 ug/kg/min of dopamine or any dose of norepinephrine
  • Neurologic: Decreased level of consciousness
  • Respiratory: Pao2:Fio2 <300
  • Renal: Oliguria, and/or Creatinine >2.0 mg/dl (>177 umol/liter)
  • Hepatic: International normalized ratio (INR) >1.5
  • Hematologic: Platelet count <100,000/mm3

* Pao2 denotes partial pressure of arterial oxygen, and Fio2 the fraction of inspired oxygen.



  1. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Kimura Y, Tsuyuguchi T, Itoi T, Yoshida M, Miura F, Yamashita Y, Okamoto K, Gabata T, Hata J, Higuchi R, Windsor JA, Bornman PC, Fan ST, Singh H, de Santibanes E, Kusachi S, Murata A, Chen XP, Jagannath P, Lee S, Padbury R, Chen MF; Tokyo Guidelines Revision Committee. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 2012 Sep;19(5):578-85. [Medline]
  2. Baron TH, Grimm IS, Swanstrom LL. Interventional Approaches to Gallbladder Disease. N Engl J Med. 2015 Jul 23;373(4):357-65. [Medline]


Created Jul 24, 2015.

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