Tokyo Guidelines for Acute Cholecystitis 2018

Tokyo 2018 Cholecystitis Calculator

A - Local Signs of Inflammation

Murphy's Sign

RUQ Mass/Pain/Tenderness

B - Systemic Signs of Inflammation

Fever (>38°C / 100.4°F)

Elevated CRP

Elevated WBC

C - Imaging Findings

Imaging Confirms Cholecystitis

Severity - Grade II (Moderate) Features

WBC >18,000/mm³

Palpable RUQ Mass

Duration of Symptoms >72 hours

Marked Local Inflammation (Gangrenous, Emphysematous, Abscess)

Severity - Grade III (Severe) Features

Cardiovascular Dysfunction

Neurological Dysfunction

Respiratory Dysfunction

Renal Dysfunction

Hepatic Dysfunction

Hematological Dysfunction (Platelet <100,000)

Tokyo 2018 Result: –

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Provides diagnostic criteria and severity grading for acute cholecystitis.

Why Use

Objectively guides diagnosis and management of patients with acute cholecystitis in terms of early or delayed surgical intervention, early or delayed gallbladder drainage, and antibiotic choice and duration.

When to Use

Use in patients with suspected acute cholecystitis (i.e., right upper quadrant tenderness, liver enzyme abnormalities, imaging findings characteristic of acute cholecystitis).

Formula

Patient must have a suspected diagnosis (≥1 item in A + ≥1 item in B or C) or definite diagnosis (≥1 item in A, B, and C) to meet entry criteria for severity grading, see table below: Diagnosis: Criteria Part A Local signs of inflammation Murphy's sign Right upper abdominal quadrant mass, pain, or tenderness Part B Systemic signs of inflammation Fever Elevated CRP Elevated WBC count Part C Imaging Imaging findings characteristic of acute cholecystitis* *e.g. pericholecystic fluid, gallstones/debris. Severity grading: Grade III (dysfunction in ≥1 of the following): 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: PaO 2 /FiO 2 ratio <300 Renal dysfunction: oliguria or creatinine >2.0 mg/dL Hepatic dysfunction: PT‐INR >1.5 Hematological dysfunction: platelet count <100,000/mm 3 Grade II (≥1 of the following conditions): Elevated WBC count (>18,000/mm 3 ) 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 I Acute cholecystitis does not meet the above criteria; no organ dysfunction and mild inflammatory changes in the gallbladder

Pearls / Pitfalls

More extensively validated in non-US populations. Conditions such as acute hepatitis and acute cholangitis may have some similarities in presentation and should be excluded, as well as chronic cholecystitis. Measurement of serum procalcitonin has not been shown to be useful for diagnosis or severity grading. If ultrasound is non-diagnostic, cholescintigraphy (HIDA) has a high sensitivity and specificity for diagnosis of acute cholecystitis. CT has low specificity. Laparoscopic cholecystectomy (LC) to treat moderate- and severe-grade acute cholecystitis (Grades II and III) has better clinical outcomes at high volume centers. The guidelines recommend using the Charlson Comorbidity Index (CCI) and ASA Physical Status to stratify patients into low risk and high risk surgical candidates.

Management

Grade I (mild): LC should ideally be performed early after onset of symptoms for low risk patients based on the CCI and ASA scores. For high risk patients ( CCI ≥6, ASA ≥3), conservative treatment can be considered initially (antibiotics, supportive care), with LC once clinical response achieved. Grade II (moderate): LC should ideally be performed early after onset of symptoms for low risk patients based on the CCI and ASA scores, preferably in a high volume center. In high risk patients ( CCI ≥6, ASA ≥3), gallbladder drainage should be considered early with delayed/elective LC. Grade III (severe): Resuscitative measures should be initiated at first with antibiotics, fluid resuscitation and vasopressor/respiratory support as needed. When considering LC, note negative predictive factors of neurological dysfunction, respiratory dysfunction, and co-existence of jaundice (total bilirubin ≥2 mg/dL). In addition, scores of CCI ≥4 and ASA ≥3 suggest high risk for LC. If an adequate clinical response is achieved in low risk patients, early LC can be considered in a high volume expert center. In high risk patients, or all patients in low volume centers, early gallbladder drainage is recommended, especially if it is not possible to control gallbladder inflammation with initial treatment.

Advice

If a definitive diagnosis cannot be made on presentation, it is reasonable to reassess the patient using the diagnostic criteria every 6-12 hours. Early LC in 3-7 days is recommended for low risk candidates. For high risk candidates, percutaneous transhepatic gallbladder drainage should be considered. Endoscopic drainage (either via EUS or ERCP ) can be considered in high volume centers. Antibiotics should be chosen based on severity of disease, location of infection (community or hospital acquired), and local susceptibilities (see Tokyo Guidelines 2018 Antimicrobial Therapy for Acute Cholangitis and Cholecystitis ).

More Information

Interpretation: Grade Acute cholecystitis severity 30day mortality I Mild 1.1% II Moderate 0.8% III Severe 5.4% Note: decrease in mortality for moderate severity is counterintuitive, but reflects limitations in the data.