Tokyo Guidelines 2018 for Acute Cholecystitis
Diagnostic criteria
Grade III (severe) organ dysfunction
Grade II (moderate) criteria
Severity grade: –
Estimated 30-day mortality: –
Interpretation: –
The Tokyo Guidelines 2018 (TG18) represent the current international standard for the management of acute cholecystitis. These guidelines, which updated the previous 2013 version (TG13), provide clinicians with a standardized framework to diagnose the condition and, more importantly, to grade its severity to determine the most appropriate treatment pathway—ranging from early surgery to emergency drainage.
1. Diagnostic Criteria for Acute Cholecystitis
The TG18 diagnosis is based on a combination of local inflammation, systemic response, and definitive imaging findings.
A. Local Signs of Inflammation
- A-1: Murphy’s sign (painful arrest of inspiration during RUQ palpation).
- A-2: Right Upper Quadrant (RUQ) mass, pain, or tenderness.
B. Systemic Signs of Inflammation
- B-1: Fever.
- B-2: Elevated C-Reactive Protein (CRP).
- B-3: Elevated White Blood Cell (WBC) count.
C. Imaging Findings
- C-1: Findings characteristic of acute cholecystitis (e.g., gallbladder wall thickening $> 4$ mm, pericholecystic fluid, gallstones/debris, or sonographic Murphy’s sign).
Diagnosis Interpretation:
- Suspected: One item in A + one item in B.
- Definitive: One item in A + one item in B + C.
2. Severity Grading (TG18)
Once a diagnosis is confirmed, the severity is assessed to guide the surgical or medical strategy.
| Grade | Description | Criteria |
| Grade III (Severe) | Organ Dysfunction | Associated with dysfunction in any one of the following: Cardiovascular (hypotension requiring inotropes), Neurological (decreased consciousness), Respiratory ($PaO_2/FiO_2$ ratio $< 300$), Renal (oliguria or Cr $> 2.0$ mg/dL), Hepatic (INR $> 1.5$), or Hematological (Platelets $< 100,000/mm^3$). |
| Grade II (Moderate) | Local Inflammation | Associated with any one of the following: Elevated WBC ($> 18,000/mm^3$), Palpable tender mass in RUQ, Duration of symptoms $> 72$ hours, or Marked local inflammation (gangrenous, abscess, peritonitis). |
| Grade I (Mild) | Healthy Patient | Does not meet the criteria of Grade II or III. Generally refers to a healthy patient with only mild inflammatory changes in the gallbladder. |
3. Management Strategy Flowchart
The TG18 introduced significant changes to how Grade III (Severe) cases are handled, moving away from “drainage-only” to “selective surgery” at advanced centers.
- Grade I (Mild): Early laparoscopic cholecystectomy (Lap-C) is the first-line treatment.
- Grade II (Moderate): Early Lap-C is preferred if the patient has a low comorbidity index (CCI $\le 5$) and the center has experienced surgeons. If the patient is high-risk, initial medical treatment or drainage followed by delayed surgery is recommended.
- Grade III (Severe): Management focuses on organ support. While gallbladder drainage was previously the default, TG18 suggests that if the patient is stable and treated at a high-volume center by expert surgeons, early Lap-C may be considered.
4. Key References and Resources
Primary Guidelines
- Yokoe M, et al. (2018). Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences. Full Text via Wiley
- Okamoto K, et al. (2018). Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences. PubMed Link
Clinical Tools
- MDCalc TG18 Calculator: A practical tool for bedside grading. Access Calculator
- JSHBPS Official Page: The Japanese Society of Hepato-Biliary-Pancreatic Surgery provides the full suite of TG18 guidelines. Official Site
