Acute Cholecystitis

Tokyo Guidelines 2018: The Tokyo guidelines provide diagnostic criteria, severity grading, and management strategies for acute cholecystitis and acute cholangitis. They were produced on the basis of the consensus achieved during discussions by global experts at the Tokyo Consensus Meeting originally held in 2007, updated in 2013, and again in 2018.

1. Diagnostic Criteria & Severity Grading

2. Flowchart for Management

3. Antimicrobial Therapy

4. Surgical Management

5. Strategies for Gallbladder Drainage

Acute Cholecystitis

1. Pathogenesis

   • Persistent GB neck occlusion 2/2 stones/sludge

2. Clinical

   • Same symptoms as biliary colic but duration > 6 h 

3. Diagnosis: The Tokyo guidelines outline three criteria for diagnosis. A suspected diagnosis is made when ≥ 1 component of both criteria A and B are met. A definite diagnosis is made when ≥ 1 component of all three (A, B, and C) are met.

   • A. local signs of inflammation

     1. Murphy sign (inspiratory pause during GB fossa palpation)

     2. RUQ mass, pain, or tenderness

   • B. systemic signs of inflammation

     1. fever

     2. ↑CRP

     3. ↑WBC

   • C. imaging

     1. RUQUS: The 2 most important features are the presence of gallstones and the sonographic Murphy sign, which together are highly specific (93.6%) for acute cholecystitis.

        • mobile hyperechoic foci that cast posterior acoustic shadowing (ie gallstones)

        • sonographic Murphy sign (maximal abdominal tenderness from pressure of the ultrasound probe over the visualized gallbladder)

        • GB wall thickening ≥ 3-4 mm

        • pericholecystic fluid

        • GB distension ≥ 9 x ≥ 4 cm (41%)

     2. CT (venous-phased): CT is not the primary imaging modality because of its low sensitivity for gallstones. It is, however, of good value in imaging possible complications (ie gangrenous cholecystitis, perforation, Mirizzi syndrome, etc.)

        • generally same findings as on RUQUS

        • pericholecystic fat stranding

        • GB mucosal enhancement

        • transient focal liver enhancement adjacent to GB

     3. HIDA: Cholescintigraphy using 99mTc-hepatic iminodiacetic acid (HIDA) may be indicated if the diagnosis remains uncertain following ultrasonography. The radiotracer is administered IV, selectively uptaken by hepatocytes, and excreted into bile ducts. HIDA has 100% negative predictive value, 90-97% sensitivity, & 71-90% specificity.

        • positive HIDA = failure to visualize gallbladder (but visualization of CBD/duodenum) w/in 1 h

        • false-positives may be seen in alcoholic liver disease, functional disorders, or pts on TPN

4. Severity: Higher severity grade is associated with increased mortality (despite an overall mortality of ~1%), length of hospital stay, conversion from laparoscopic to open, complications esp. bile duct injuries, & higher medical costs.

   • grade 1 (mild)

     1. not grade 2 or 3

   • grade 2 (moderate): ≥ 1 of

     1. WBC > 18

     2. palpable RUQ mass

     3. duration > 72 h

     4. gangrenous cholecystitis

     5. pericholecystic abscess

     6. hepatic abscess

     7. biliary peritonitis

     8. emphysematous cholecystitis

   • grade 3 (severe): ≥ 1 of

     1. hypotension requiring dopamine ≥ 5 mcg/kg/min or any norepinephrine

     2. AMS

     3. P/F ratio < 300

     4. oliguria or Cr > 2.0

     5. INR > 1.5

     6. Plt < 100

5. Antibiotics

   • grade 1: any of the following

     1. Unasyn (not recommended if > 20% local resistance)

     2. ertapenem

     3. cefazolin + metronidazole

     4. ciprofloxacin + metronidazole

   • grade 2: any of the following

     1. Zosyn 3.375 mg Q8H

     2. ertapenem

     3. ceftriaxone + metronidazole

     4. ciprofloxacin + metronidazole

   • grade 3: any of the following

     1. Zosyn 4.5 mg Q8H

     2. meropenem

     3. cefepime + metronidazole

6. therapy: guided by Charlson Comorbidity Index (CCI) and ASA class

   • grade 1

     1. CCI ≤ 5 and/or ASA ≤ 2: early lap chole

     2. CCI > 5 and/or ASA > 2: abx f/b delayed lap chole

   • grade 2

     1. if abx/supportive tx succeeds

        • CCI ≤ 5 and/or ASA ≤ 2: early lap chole

        • CCI > 5 and/or ASA > 2: delayed lap chole

     2. if abx/supportive tx fails: urgent GB drainage

   • grade 3

     1. early lap chole only for select pts

        • no jaundice, TBili < 2, no AMS, P/F > 300

        • CV/renal failure rapidly reversed after admission

     2. all other pts undergo urgent GB drainage

        • delayed lap chole if CCI < 4 and/or ASA < 3

        • continued obs if CCI ≥ 4 and/or ASA ≥ 3

   • complications

     1. gangrenous cholecystitis (up to 20%)

        • pathogenesis: GB necrosis

        • clinical: ↑age, DM, delayed presentation

        • diagnosis

          1. IV-contrasted CT: 73% SN vs 95% NPV

          2. IV-contrasted MRI: 80% accuracy

             • irregular GB wall thickening

             • poor GB wall enhancement (interrupted rim sign)

             • pericholecystic fat stranding

             • gas in GB lumen or wall

             • membranes w/in lumen (intraluminal flap)

             • pericholecystic abscess

     2. emphysematous cholecystitis

        • pathogenesis: GB wall infection w/aerogenic bacteria

        • risk factors: DM

        • microbiology: Clostridium welchii > E. coli

        • clinical: RUQ crepitus (rare but unique sign)

        • diagnosis: non-contrasted CT (gas in GB wall)

     3. GB perforation (10%)

        • usually localized as pericholecystic abscess

        • rarely disseminates as biliary peritonitis

     4. abscess (intra-abdominal, pericholecystic)

     5. biliary peritonitis & sepsis

     6. abdominal wall gas gangrene