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Tokyo Guidelines for Acute Cholecystitis 2018 (TG18)
Tokyo Guidelines for Acute Cholecystitis 2018 (TG18)
A. Local signs of inflammation (Murphy's sign, or RUQ mass / pain / tenderness)
B. Systemic signs of inflammation (fever, elevated CRP, or elevated WBC)
C. Imaging findings characteristic of acute cholecystitis
Grade III: organ dysfunction (vasopressor-requiring hypotension, altered consciousness, PaO2/FiO2 <300, creatinine >2 mg/dL, INR >1.5, or platelets <100k)
WBC >18,000 /uL
Palpable tender mass in the right upper quadrant
Duration of complaints >72 hours
Marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic/hepatic abscess, biliary peritonitis)
ResultDiagnostic criteria not met
Requires one item from A plus one from B to be suspected.
- Diagnosis
- Diagnostic criteria not met
When to use
- Confirming a diagnosis of acute cholecystitis and grading severity to guide the timing and type of intervention.
Formula
Suspected: one A item (local inflammation) plus one B item (systemic inflammation). Definite: A and B plus C (imaging). Grade III = any organ dysfunction; Grade II = any of (WBC >18k, palpable tender RUQ mass, symptoms >72 h, marked local inflammation); Grade I = neither.
Pearls and pitfalls
- Early laparoscopic cholecystectomy is favoured for Grade I and selected Grade II disease.
- Grade III requires organ support and often initial gallbladder drainage.