What are the Tokyo Guidelines for diagnosing, severity grading, and managing acute cholecystitis?

Tokyo Guidelines for Acute Cholecystitis

The Tokyo Guidelines (most recently updated as TG18/TG13) provide a standardized framework for diagnosing acute cholecystitis based on clinical signs, laboratory findings, and imaging confirmation, with severity grading into three categories (Grade I-III) that directly guide surgical timing and management decisions. 1

Diagnostic Criteria

The diagnosis of acute cholecystitis requires both local and systemic signs of inflammation, with imaging confirmation for definitive diagnosis 2, 1:

Clinical and Laboratory Findings (Suspected Diagnosis)

• Local signs of inflammation:

  • Murphy's sign (inspiratory arrest during right upper quadrant palpation)
  • Right upper quadrant pain or tenderness
  • Palpable mass in right upper quadrant 2, 3

• Systemic signs of inflammation:

  • Fever
  • Elevated white blood cell count
  • Elevated C-reactive protein 2, 3

Imaging Confirmation (Definite Diagnosis)

Definite diagnosis requires imaging evidence using ultrasonography, computed tomography, or scintigraphy (HIDA scan) showing gallbladder inflammation 2, 1. The TG13 revision improved specificity from 93.3% to 96.9% and accuracy from 92.7% to 94.0% by requiring imaging confirmation rather than relying solely on clinical findings 4.

Important caveat: No single clinical or laboratory finding has sufficient diagnostic power alone; a combination of detailed history, physical examination, laboratory tests, and imaging is essential 5.

Severity Grading

The Tokyo Guidelines classify acute cholecystitis into three severity grades that have been validated to correlate with 30-day mortality, hospital length of stay, conversion to open surgery rates, and medical costs 1:

Grade I (Mild)

• No organ dysfunction
• Limited disease in the gallbladder
• Cholecystectomy is a low-risk procedure 2, 3

Grade II (Moderate)

• No organ dysfunction but extensive gallbladder disease
• Characterized by:
  • Elevated white blood cell count (>18,000/mm³)
  • Palpable tender mass in right upper quadrant
  • Disease duration >72 hours
  • Significant inflammatory changes on imaging 2, 3

Grade III (Severe)

• Presence of organ dysfunction in any of the following systems:
  • Cardiovascular dysfunction
  • Neurological dysfunction
  • Respiratory dysfunction
  • Renal dysfunction
  • Hepatic dysfunction
  • Hematological dysfunction 2, 3

Management Approach

Early laparoscopic cholecystectomy (ELC) has a central role in management for all grades of acute cholecystitis, with surgery being the gold standard treatment 5. The WSES 2020 guidelines, which evaluated and largely aligned with TG18, recommend a more liberal indication for surgery including Grade III disease 5.

Surgical Timing by Severity

• Grade I and II: Early laparoscopic cholecystectomy is recommended 5
• Grade III: Surgery is increasingly recommended rather than drainage alone, though distinction must be made between high-risk patients and those truly unsuitable for surgery 5

Exceptions to Surgical Management

Only two scenarios warrant non-surgical management 5:

• Patients who refuse surgery
• Patients for whom surgery would be considered "very high risk" (though this remains an area requiring better definition and clinical judgment) 5

Critical pitfall: The WSES guidelines note that TG13 criteria had "limited quality evidence" linking diagnostic criteria directly to severity classification and therapeutic indications, and emphasize that old age alone should not be considered a contraindication to surgery 5, 6.