Select the highest severity criteria identified to visualize the TG18 management profile for acute cholecystitis.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Diagnosis and severity grading of suspected Acute Cholecystitis
To guide the timing and modality of surgery (Laparoscopic Cholecystectomy)
Standardizing clinical evaluation of right upper quadrant (RUQ) pain
Clinical Suspicion
Acute cholecystitis should be suspected in any patient with prolonged RUQ pain, fever, and a positive Murphy's sign, especially in those with known gallstones.
Section 2
Formula & Logic
TG18 Diagnostic Criteria
01
A. Local Signs: Murphy's sign OR RUQ mass/pain/tenderness.
02
B. Systemic Signs: Fever OR Elevated CRP OR Elevated WBC count.
03
C. Imaging Signs: Gallbladder wall thickening (> 4mm), enlargement, or peri-cholecystic fluid.
Thresholds
Suspected
One item in A + One item in B
Definite
One item in A + One item in B + One item (C)
Severity Grading (Grade I–III)
01
Grade III (Severe): Associated with organ failure (CV, Neuro, Resp, Renal, Hepatic, or Heme).
02
Grade II (Moderate): No organ failure but 1+ features (WBC > 18, Palpable tender mass, Duration > 72h, or marked local inflammation).
03
Grade I (Mild): Healthy patient; No organ failure; Mild inflammatory gallbladder changes only.
Section 3
Pearls/Pitfalls
Early vs. Delayed Cholecystectomy
Modern guidelines (TG18) strongly favor early laparoscopic cholecystectomy (within 72 hours of symptom onset) for Grade I and II patients. Historically, clinicians "cooled down" the gallbladder with antibiotics, but RCTs have proven that early surgery reduces morbidity and total hospital stay.
The Grade III Challenge
For Grade III (Severe) patients with organ failure, immediate surgery is high-risk. These patients often benefit from percutaneous transhepatic gallbladder drainage (PTGBD) as a "bridge" to stabilize the sepsis before elective surgery several weeks later.
Clinical Pearls
The "Sonographic Murphy Sign" (pain with scope pressure) is the most specific radiological sign of cholecystitis
CRP > 1.0 mg/dL is a mandatory systemic signal in the TG18 criteria in the absence of high fever or leukocytosis
Emphysematous cholecystitis (gas in the wall) is a surgical emergency and mandates immediate Grade III-level management
Section 4
Next Steps
Management Action
01
Grade I: Early Laparoscopic Cholecystectomy.
02
Grade II: Early Laparoscopic Cholecystectomy; favor expert surgeon for anticipated difficult dissection.
03
Grade III: Systemic support; IV Antibiotics; Urgent PTGBD if not responding to conservative therapy.
Complementary Scoring
Tokyo Guidelines (Cholangitis)
ASGE Choledocholithiasis Risk
Cotton Criteria (ERCP Complications)
Section 5
Evidence Appraisal
The Global Guidelines (TG18)
Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).
Yokoe M et al. • Journal of Hepato-Biliary-Pancreatic Sciences. 2018;25(1):41-54. The international consensus standard.
