The document provides guidelines for the management of acute cholecystitis from the 2018 Tokyo Guidelines. It discusses diagnostic criteria for acute cholecystitis, including symptoms, lab/imaging findings, and severity grading into mild (Grade I), moderate (Grade II), or severe (Grade III). Treatment recommendations are provided based on severity grade. For mild cases, cholecystectomy is recommended, while for moderate/severe cases, cholecystectomy or percutaneous drainage is recommended based on patient risk factors and institutional capabilities. The guidelines also discuss criteria for transferring patients to specialized centers able to provide intensive care and urgent cholecystectomy or drainage procedures.

1. TOKYO GUIDELINES 2018 -
MANAGEMENT OF ACUTE CHOLECYSTITIS
PRESENTOR : DR ZULHAIMI
SUPERVISOR : MR GOO

2. Hello!
I am
ZULHAIMI WAHID
Sit back and enjoy this short
presentation!
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3. Content
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Case study
The Gallbladder
Diagnostic Criteria
Severity Grading
Management

4. Case study
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5. Case study
▷ 31 years old, Male
▷ Underlying hypertension (defaulted)
▷ P/W : Right hypochondrium pain x 1/52, no fever/no jaundice/no
GI loss
▷ Clinically not septic, VS stable, PA tender over RHC, Murphy sign
+ve
▷ Blood ix :
○ FBC - WBC : 13.68/ HB 16.6/ HCT 51/PLATELETS 376
○ LFT - TP : 84/ALB 46/GLOB 38/TB 10/ALP 72/ ALT 41
○ RP - NA 137/ K 4.1/CL 103/UREA 3.4/CREAT 72
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6. ▷ USG ABDOMEN :
No biliary tree dilatation.
Gallbladder is well distended.
Calculus seen measuring 0.6cm with gallbladder sludge.
No pericholecystic collection.
No GB wall thickening
No renal lesion, calculi or hydronephrosis bilaterally.
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7. Tokyo Guidelines 2018
Management of
Acute Cholecystitis
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9. Gallbladder and Biliary system
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10. Etiology
1. Acute calculous cholecystitis :
○ Pathophysiology : Cholelithiasis → passage of gallstones into
the cystic duct → cystic duct obstruction → distention and
inflammation of the gallbladder
○ Secondary bacterial infection may also be present (E. coli,
Klebsiella, Enterobacter, Enterococcus spp.)
2. Acalculous cholecystitis :
○ Conditions predisposing to bile stasis and reduced perfusion of
the gallbladder
○ Risk factors : Multiorgan failure (critically ill patients), severe trauma,
burns, surgery, infection (e.g: CMV), sepsis/septic shock, total
parenteral nutrition, prolonged fasting, immunodeficiency
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11. Diagnostic Criteria
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• Murphy’s sign
• RUQ mass/pain/tenderness
A - Local signs of inflammation
• Fever
• Elevated CRP / WBC count
B - Systemic signs of inflammation
• Thickening of the gallbladder wall (≥4mm)
• Gallbladder enlargement (long axis ≥8 cm, short axis ≥4 cm)
• Gallstones or retained debris
• Ultrasonographic Murphy’s sign
• Gas imaging
• Pericholecystic fluid
C - Imaging findings
Suspected
Diagnosis
• one item in A +
one item in B
Definite
Diagnosis
• one item in A +
one item in B +
C

13. Imaging modalities – USG
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• low invasiveness
• widespread availability
• ease of use
• cost-effectiveness

14. Imaging modalities – MRI / CECT
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MRI
(a) : Early phase
Arrow : gallstones
(b) : Portal venous phase
Arrow : GB wall
CECT
(c) : Early phase
(d) : Portal venous phase

15. Imaging modalities : MRCP
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(a) MRI T2 weighted
image
→ : GB wall thickening
▷ : hypointense
gallstone
(b) MRI T2 diffusion
weighted image
→ : GB wall thickening
✽ : deposition of debris
at neck of GB
(c) MRCP
→ : aberrant posterior
hepatic duct
✽ : neck of GB

16. Severity Grading
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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 III (severe) acute cholecystitis

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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 hr
4. Marked local inflammation (gangrenous cholecystitis,
pericholecystic abscess, hepatic abscess, biliary
peritonitis, emphysematous cholecystitis)
Grade II (moderate) acute cholecystitis

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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
Grade I (mild) acute cholecystitis

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22. Management
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While considering indications for surgery and emergency drainage, sufficient infusion and
electrolyte correction take place, and antimicrobial and analgesic agents are administered
while fasting continuing the monitoring of respiratory and hemodynamics.

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27. Grade I (mild) AC
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28. Grade II (moderate) AC
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29. Grade III (severe) AC
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Negative predictive factors :
• jaundice (TBil ≥2)
• neurological dysfunction
• respiratory dysfunction
Favorable organ system
failure (FOSF) :
rapidly reversible after admission
and before early LC in AC
• Cardiovascular failure
• Renal failure

30. Transfer criteria
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• When a patient meets certain conditions defined by the AC flowchart, Lap-C can be
performed only by an expert laparoscopic surgeon at a specialized center that
provides intensive care.
• Otherwise, transfer to advanced facilities should be considered
Severe acute cholecystitis (Grade III)
• Patients should be treated at centers that can provide emergent drainage of the
gallbladder or early Lap-C. Otherwise, transfer to advanced facilities should be
considered
Moderate acute cholecystitis (Grade II)
• In the case of patients whose operation is delayed because of existing serious
comorbidity transfer to advanced facilities that can provide emergent drainage of
the gallbladder or early Lap-C should be considered
Mild acute cholecystitis (Grade I)

31. Update on case study
▷ Treated as acute cholecystitis
▷ Discharge with antibiotics and analgesia on D2 admission
▷ Planned for Laparoscopic Cholecystectomy KIV Open on 16/5/23
▷ OGDS on 5/5/23
▷ Pre-Anaesth Clinic and SOPD review on 11/5/23
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32. Thank You
Any questions?
For you attention
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