What organ dysfunction manifestations define Grade III (severe) acute cholecystitis?

Grade III (Severe) Acute Cholecystitis: Organ Dysfunction Manifestations

Grade III (severe) acute cholecystitis is defined by the presence of organ dysfunction, which carries a 28-day mortality risk of approximately 6.5% compared to 1.3% for Grade I disease. 1

Defining Organ Dysfunction in Grade III Acute Cholecystitis

The Tokyo Guidelines establish that Grade III acute cholecystitis is characterized by at least one new-onset organ dysfunction, distinguishing it from Grade I (mild disease with no organ dysfunction) and Grade II (moderate disease with extensive gallbladder inflammation but no organ dysfunction). 2, 3

Specific Organ Dysfunction Criteria

Cardiovascular dysfunction manifests as:

• Hypotension requiring vasopressor support (dopamine >5 μg/kg/min or any dose of epinephrine/norepinephrine) 1
• Mean arterial pressure <70 mmHg despite fluid resuscitation 1
• Shock requiring intensive care unit admission 1

Neurological dysfunction presents as:

• Altered mental status or decreased consciousness 1
• Confusion or disorientation requiring close monitoring 2

Respiratory dysfunction includes:

• PaO₂/FiO₂ ratio ≤300 or requirement for mechanical ventilation 1
• Respiratory failure necessitating oxygen support beyond baseline requirements 1
• Pulmonary complications such as pulmonary embolism 1

Renal dysfunction is defined as:

• Acute kidney injury with creatinine ≥2.0 mg/dL 1
• Acute renal failure requiring renal replacement therapy 1
• Progressive azotemia unresponsive to fluid resuscitation 2

Hepatic dysfunction manifests as:

• Progressive jaundice with bilirubin ≥12 mg/dL 1
• Acute liver injury beyond baseline cirrhotic changes 1

Hematologic dysfunction presents as:

• Coagulopathy with INR ≥2.5 or platelet count ≤20,000/mm³ 1
• Disseminated intravascular coagulation 2

Other systemic manifestations include:

• Myocardial infarction or acute coronary syndrome 1
• Acute stroke 1
• Heart failure decompensation 1

Clinical Context and Risk Stratification

The presence of organ dysfunction fundamentally changes management priorities. Patients with Grade III disease require immediate intensive care unit admission, aggressive resuscitation, and urgent consideration for biliary drainage or surgical intervention at high-volume specialized centers. 1

The severity assessment should be performed using systematic evaluation of all organ systems, as multiorgan dysfunction syndrome develops rapidly in severe acute cholecystitis. 4 The Sequential Organ Failure Assessment (SOFA) score can track progression, with cardiovascular and respiratory dysfunction being the most dynamic parameters. 4

Critical pitfall: Do not delay recognition of organ dysfunction by attributing symptoms solely to local gallbladder inflammation. Fever, tachycardia, and leukocytosis alone do not define Grade III disease—specific organ dysfunction criteria must be met. 2, 3

Mortality implications: Grade III acute cholecystitis carries a 6.5% mortality risk (95% CI 3.7-11.2%), representing a five-fold increase over Grade I disease. 1 This mortality risk is comparable to ACLF Grade III in cirrhotic patients, where three or more organ failures result in 78% 28-day mortality. 1