What are the Tokyo guidelines for managing acute cholecystitis?

Tokyo Guidelines for Managing Acute Cholecystitis

The Tokyo Guidelines recommend early laparoscopic cholecystectomy as the treatment of choice for acute cholecystitis, with treatment strategies stratified by severity grade and patient risk factors. 1, 2

Diagnostic Criteria

The Tokyo Guidelines use the following criteria for diagnosing acute cholecystitis:

• Clinical signs: Fever/chills, right upper quadrant pain or epigastric pain, and jaundice (Charcot's triad)
• Laboratory findings: Elevated inflammatory markers (WBC, CRP)
• Imaging findings: Ultrasonography (first-line), MRCP, or EUS showing gallbladder wall thickening, gallstones, or pericholecystic fluid

Severity Grading System

The Tokyo Guidelines classify acute cholecystitis into three grades:

• Grade I (Mild): Acute cholecystitis in a healthy patient without organ dysfunction
• Grade II (Moderate): Associated with any of: elevated WBC (>18,000/mm³), palpable tender mass in RUQ, duration >72 hours, marked local inflammation
• Grade III (Severe): Associated with organ system dysfunction

Management Algorithm

Grade I (Mild) Acute Cholecystitis

• Recommended treatment: Early laparoscopic cholecystectomy if CCI ≤5 and ASA-PS ≤2 1
• Antibiotic therapy recommended perioperatively 3
• Post-operative antibiotics not recommended 3

Grade II (Moderate) Acute Cholecystitis

• If CCI ≤5 and ASA-PS ≤2: Early laparoscopic cholecystectomy by experienced surgeons 1
• If higher risk: Initial medical treatment and/or gallbladder drainage, followed by delayed laparoscopic cholecystectomy 1
• Antibiotic therapy recommended perioperatively 3
• Post-operative antibiotics not recommended for mild to moderate cases 3

Grade III (Severe) Acute Cholecystitis

• If favorable organ system failure, CCI ≤3, ASA-PS ≤2, and at advanced center: Early laparoscopic cholecystectomy may be considered 1
• Otherwise: Urgent biliary drainage followed by delayed cholecystectomy once condition improves 1
• Maximum 4 days of antibiotic therapy recommended 3

Biliary Drainage Options

When early surgery is not feasible or too risky:

1. ERCP (Endoscopic Retrograde Cholangiopancreatography): First-line drainage method for moderate/severe acute cholangitis 4, 2

   • Success rate >90% for stone extraction 4

2. PTGBD (Percutaneous Transhepatic Gallbladder Drainage): Alternative when ERCP fails 4, 5

   • Safe and effective for critically ill patients 4

3. PTGBA (Percutaneous Transhepatic Gallbladder Aspiration): Less invasive alternative 5

4. EUS-guided drainage: Emerging alternative after failed ERCP 4

Antibiotic Management

• Timing: Initiate empiric antibiotics as soon as possible upon clinical suspicion 2

  • Within 1 hour for patients with septic shock
  • Within 4 hours for other cases

• Coverage: Broad-spectrum antibiotics covering enteric Gram-negative bacteria and enterococci 2

• Duration:

  • For severe (Grade III) cholecystitis: Maximum 4 days 3
  • For mild/moderate cases with successful drainage: No post-operative antibiotics needed 3

Important Considerations

• Early cholecystectomy results in shorter recovery time and hospitalization compared to delayed procedures 4
• Cholecystostomy is a safe alternative for critically ill patients unfit for surgery 4
• Early diagnosis of gallbladder perforation and immediate surgical intervention significantly decreases morbidity and mortality 4
• Conservative management (antibiotics with or without drainage) should be considered a bridge to surgery rather than definitive treatment due to frequent recurrence 6

Timing of Biliary Decompression in Cholangitis

For patients with acute cholangitis (often associated with cholecystitis):

• Grade 3 (severe): Urgent decompression
• Grade 2 (moderate): Early decompression (<24 hours after admission) significantly reduces 30-day mortality 4
• Grade 1 (mild): Can be initially observed on medical treatment 4

The Tokyo Guidelines provide a comprehensive, evidence-based approach to managing acute cholecystitis with treatment strategies tailored to disease severity and patient factors.