Acute cholecystitis

Sonographic criteria of acute cholecystitis[35]Bortoff GA, Chen MY, Ott DJ, et al. Gallbladder stones: imaging and intervention. Radiographics. 2000 May-Jun;20(3):751-66. http://www.ncbi.nlm.nih.gov/pubmed/10835126?tool=bestpractice.com

• Pericholecystic fluid

• Distended gallbladder

• Thickened gallbladder wall (>3 mm)

• Gallstones

• Positive sonographic Murphy 's sign.

TG18/TG13 severity grading for acute cholecystitis[34]Yokoe M, Hata J, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. https://onlinelibrary.wiley.com/doi/full/10.1002/jhbp.515 http://www.ncbi.nlm.nih.gov/pubmed/29032636?tool=bestpractice.com

The Tokyo guidelines use a grading system of mild, moderate, and severe to classify severity. Treatment can be based on this classification.

Severe (grade III) acute cholecystitis is associated with dysfunction of any one of the following organs/systems.

1. Cardiovascular: hypotension requiring treatment with dopamine ≥5 micrograms/kg per minute, or any dose of noradrenaline (norepinephrine).

2. Neurological: decreased level of consciousness.

3. Respiratory: PaO₂/fraction of inspired oxygen (FiO₂) ratio <300.

4. Renal: oliguria, creatinine >2.0 mg/dL.

5. Hepatic: prothrombin time – international normalised ratio (PT‐INR) >1.5.

6. Haematological: platelet count <100,000/mm³. 

Moderate (grade II) acute cholecystitis is associated with any one of the following conditions.

1. Elevated white blood cell count (>18,000/mm³).

2. Palpable tender mass in the right upper abdominal quadrant.

3. Duration of complaints >72 hours.

4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).

Mild (grade I) acute cholecystitis:

• Acute cholecystitis that 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.