Suspected Acute Cholecystitis
Patient with RUQ pain, fever, and/or Murphy sign. Consider if: local signs (RUQ pain/tenderness, Murphy sign) + systemic signs (fever, elevated CRP, leukocytosis) + imaging findings
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General SurgeryEmergency
Acute Cholecystitis Management (TG18 2018)
Acute Cholecystitis Management (TG18 2018): Suspected Acute Cholecystitis → TG18 Diagnostic Criteria Met? → Determine TG18 Severity Grade → Grade I (Mil...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Decision TG18 Diagnostic Criteria Met?
A: Local signs (Murphy sign, RUQ mass/pain/tenderness) + B: Systemic inflammation (fever >38°C, CRP elevated, WBC >10,000/mm³) + C: Imaging findings (US/CT showing gallbladder wall thickening >4mm, pericholecystic fluid, gallstones). Definite: A + B + C. Suspected: A + B
03Decision Determine TG18 Severity Grade
Grade I (Mild): No organ dysfunction, mild inflammatory changes. Grade II (Moderate): WBC >18,000/mm³ OR palpable RUQ mass OR duration >72h OR marked local inflammation (gangrenous, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous). Grade III (Severe): Organ dysfunction in any system
04Action Grade I (Mild)
No organ dysfunction and mild disease. Local inflammation only.
05Decision Surgical Risk Assessment
Assess Charlson Comorbidity Index (CCI) and ASA Physical Status (ASA-PS). Early Lap-C if CCI ≤5 AND ASA-PS ≤2
06Action Early Laparoscopic Cholecystectomy
Perform Lap-C as soon as possible, ideally within 72 hours of symptom onset. Early surgery reduces conversion rates, complications, and hospital stay.
07Action Antibiotic Selection (TG18)
Community-acquired Grade I-II: Cefazolin or ceftriaxone. Grade II with risk factors or Grade III: Piperacillin-tazobactam, carbapenem, or cephalosporin + metronidazole. Healthcare-associated: Add vancomycin for MRSA coverage. Duration: Until cholecystectomy for uncomplicated; 4-7 days post source control for complicated.
08Outcome Cholecystectomy Completed
Definitive surgical management achieved. Routine postoperative care. Pathology review for gangrenous/malignancy.
09Outcome Drainage + Delayed Surgery
Patient stabilized with drainage. Plan interval cholecystectomy in 6-8 weeks. Follow-up imaging to confirm resolution.
10Action Conservative Management
IV fluids, bowel rest, IV antibiotics. Consider percutaneous gallbladder drainage if no improvement in 24-48h. Plan delayed Lap-C after inflammation resolves (6-8 weeks).
- Path rejoins step 07Shared downstream outcome
11Action Grade II (Moderate)
Marked local inflammation: WBC >18,000/mm³, palpable mass, duration >72h, or local complications (gangrenous, abscess)
12Decision Advanced Laparoscopic Skills Available?
Assess surgical expertise and patient factors. Experienced laparoscopic surgeon at advanced center? Patient CCI and ASA-PS acceptable for surgery?
13Action Early Lap-C by Expert Surgeon
Perform Lap-C with experienced surgeon. Higher conversion risk but acceptable. Consider subtotal cholecystectomy if severe inflammation.
- Path rejoins step 07Shared downstream outcome
14Action Early Biliary Drainage
Percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic approach. Stabilize patient. Plan delayed cholecystectomy once inflammation resolves.
- Path rejoins step 07Shared downstream outcome
15Action Grade III (Severe)
Organ dysfunction present: CV (hypotension requiring vasopressors), Neurological (decreased consciousness), Respiratory (PaO2/FiO2 <300), Renal (oliguria, Cr >2.0), Hepatic (PT-INR >1.5), Hematologic (Plt <100,000)
16Action Intensive Organ Support
ICU admission. Aggressive resuscitation: IV fluids, vasopressors if needed, respiratory support. Initiate broad-spectrum antibiotics immediately.
17Action Urgent Biliary Drainage
PTGBD is first-line for source control. Endoscopic drainage as alternative. NOT early cholecystectomy - too high risk. Cholecystectomy only after full recovery and optimization.
- Path rejoins step 07Shared downstream outcome
18Warning ⚠️ Watch for Gangrenous Cholecystitis
Signs: persistent fever despite antibiotics, high WBC, gas in gallbladder wall (emphysematous), perforation on imaging. Requires urgent surgery or drainage even if Grade III. Mortality significantly increased if delayed.
Guideline Source
Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address acalculous cholecystitis in detail
- Pediatric patients require specialized consideration
- Pregnancy requires modified approach
- Local surgical expertise influences Grade III management decisions
- Institutional protocols may vary for biliary drainage techniques
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
Global: TG18 is the international standard for acute cholecystitis management
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Acute Cholecystitis Management (TG18 2018)?
The Acute Cholecystitis Management (TG18 2018) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.
What guideline is the Acute Cholecystitis Management (TG18 2018) based on?
This algorithm is based on Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis (DOI: 10.1002/jhbp.516).
What are the limitations of the Acute Cholecystitis Management (TG18 2018)?
Known limitations include: Does not address acalculous cholecystitis in detail; Pediatric patients require specialized consideration; Pregnancy requires modified approach; Local surgical expertise influences Grade III management decisions; Institutional protocols may vary for biliary drainage techniques. Individual patient factors may require deviation from these recommendations.
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