This document summarizes guidelines from the Tokyo Guidelines 2018 (TG18) for the management of acute cholecystitis. It recommends continuing to use the diagnostic criteria and severity grading from TG13. Ultrasound is recommended as the first choice imaging method due to its low invasiveness and cost-effectiveness. Contrast CT or MRI can help diagnose gangrenous cholecystitis. Laparoscopic cholecystectomy is recommended over open cholecystectomy. Early cholecystectomy within 72 hours of onset is optimal but may still provide benefits even after 72 hours. The optimal timing for cholecystectomy after percutaneous gallbladder drainage is uncertain due to lack of evidence, but studies suggest waiting 4-6

1. MANAGEMENT OF ACUTE CHOLECYSTITS
TOKYO GUIDELINES 2018 (TG18)
By: Dr Wan Shahfuan

3. Diagnostic criteria and severity grading of acute
cholecystitis
Q1. Is TG13 diagnostic criteria of acute cholecystitis
recommended to use as TG18 diagnostic criteria?
[Foreground question (clinical question)]
The TG13 diagnostic criteria for acute cholecystitis have high
sensitivity and specificity and good diagnostic yield;
therefore, their use as the TG18 diagnostic criteria for acute
cholecystitis is recommended. (Recommendation 1, level C)

5. Q3. Is ultrasonography (US) recommended for diagnosing
acute cholecystitis?
Although the diagnostic criteria for the diagnosis of acute
cholecystitis by US and its diagnostic yield vary in different
studies, its low invasiveness, widespread availability, ease of
use, and cost-effectiveness make it recommended as the
first-choice imaging method for the morphological diagnosis
of acute cholecystitis. (Recommendation 1, level C)
US has 81% sensitivity and 83% specificity

7. Contrast-enhanced CT
Contrast-enhanced CT or contrast-enhanced MRI is recommended for
diagnosing gangrenous cholecystitis. (Recommendation 2, level C).
Gangrenous cholecystitis exhibits specific findings on dynamic CT, including:
• Irregular thickening of the gallbladder wall
• Poor contrast enhancement of the gallbladder wall (interrupted rim sign)
• Increased density of fatty tissue around the gallbladder
• Gas in the gallbladder lumen or wall
• Membranous structures within the lumen (intraluminal flap or intraluminal
membrane)
• Peri-gallbladder abscess

9. Q6. Is TG13 severity grading of acute cholecystitis
recommended to use as TG18 severity grading?
Grade III (severe) acute cholecystitis in the TG13 severity grading of
acute cholecystitis causes systemic symptoms due to organ
damage and affects survival prognosis. The TG13 severity grading
of acute cholecystitis is recommended for use as the TG18 severity
grading of acute cholecystitis as a useful indicator from the
perspective of predicting prognosis, among others.
(Recommendation 1, level C)

10. Grade III (severe) acute cholecystitis
Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:
1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of
norepinephrine
2. Neurological dysfunction: decreased level of consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio <300
4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT-INR >1.5
6. Hematological dysfunction: platelet count <100,000/mm3
Grade II (moderate) acute cholecystitis
“Grade II” acute cholecystitis is associated with any one of the following conditions:
1. Elevated WBC count (>18,000/mm3)
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis,
emphysematous cholecystitis)
Grade I (mild) acute cholecystitis
Grade I” acute cholecystitis 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
TG18/TG13 severity grading for acute cholecystitis

12. Flowchart for the management of acute cholecystitis
What is the initial medical treatment of acute cholecystitis?
While considering indications for surgery and emergency drainage,
sufficient infusion and electrolyte correction take place, and
antimicrobial and analgesic agents are administered while
continuing the monitoring of respiratory and hemodynamics.
(Level C)

13. Antimicrobial therapy for acute cholecystitis

16. Q1. Is laparoscopic cholecystectomy recommended for acute
cholecystitis compared to open cholecystectomy?
We propose Lap-C for AC over open cholecystectomy.
(Recommendation 2, level A)
Laparoscopy seems to be the treatment of choice for AC around the world.
It is generally expected to result in less pain at incision sites, shorter hospital stays and recovery
periods, and better quality of life

17. Q2. What is the optimal treatment for acute cholecystitis
according to the grade of severity?
TG18 guidelines define neurological dysfunction,
respiratory dysfunction, and coexistence of
jaundice (TBil ≥2 mg/dl) as negative predictive
factors
Renal dysfunction and cardiovascular dysfunction
are considered types of favorable organ system
failure (FOSF) and are therefore defined as “non-
negative predictive factors,”

18. Q3. What is the optimal timing of cholecystectomy for acute
cholecystitis?
If a patient is deemed capable of withstanding surgery for AC, we
propose early surgery regardless of exactly how much time has passed
since onset. (Recommendation 2, level B)

19. TG13 recommended that surgery be performed soon after admission
and within 72 h after onset.
However, in TG18 further considerations has been on whether the
“within 72 h” rule should be strictly observed based on studies done
after TG13.
Meta - analysis (Early vs Delayed Cholecystectomy):
• Operating time: shorter operating time in delayed cholecystectomy
• Incidence of bile duct injury: no significant difference
• Length of hospital stay: shorter in early cholecystectomy
• Overall medical cost: lower for early cholecystectomy
Conclusion: There still are benefits to performing surgery early although
it has been > 72 hrs

20. Q4. When is the optimal timing for cholecystectomy following
percutaneous transhepatic gallbladder drainage (biliary
drainage)?
There are no reports providing
quality scientific evidence on the
best timing for surgery after
percutaneous transhepatic
gallbladder drainage (PTGBD;
also called cholecystostomy), so
a consensus has not been
reached. (Level C)
Studies from Ahmed El-Gendi et al and Feza Y Karakayali et al both reported good outcomes
when Lap-C was performed after waiting 4–6 weeks after PTGBD for the factors bleeding
volume, operating times, percentage of patients switched to open surgery, and incidence of
complications

22. Thank You