Acute Cholecystitis

Acute cholecystitis is defined by Murphy's sign, fever, RUQ pain, and USS findings. The Tokyo Guidelines 2018 grade severity: Grade I (mild — no organ dysfunction), Grade II (moderate — local complications), Grade III (severe — organ dysfunction)…

Tokyo Guidelines 2018 (TG18)

The pathway

1 · Clinical diagnosis

Murphy's sign: arrest of inspiration on palpation of RUQ (high specificity)
RUQ tenderness and guarding
Fever >38°C
WBC >10 × 10⁹/L
CRP >3mg/L
Two of three (local signs, systemic inflammation, imaging confirmation) = definite diagnosis

2 · USS abdomen

Gallstones: high sensitivity/specificity
Pericholecystic fluid: inflammation
Wall thickening >3mm: hallmark of cholecystitis
Sonographic Murphy's sign: USS probe pressure reproduces Murphy's sign
Gallbladder distension: >5cm transverse diameter

3 · Tokyo grading

Grade I (Mild): no organ dysfunction, resolves with conservative treatment; safe for early cholecystectomy
Grade II (Moderate): local complications (empyema, pericholecystic abscess, gangrenous cholecystitis) without organ dysfunction
Grade III (Severe): organ dysfunction in ≥1 system (cardiovascular, neurological, respiratory, renal, hepatic, haematological)

4 · Initial management

NBM immediately
IV fluid resuscitation (Hartmann's)
Analgesia: morphine 5–10mg IV (adequate analgesia is safe and does not mask signs)
Antiemetic: ondansetron 4mg IV
Bloods: FBC, LFTs, amylase, CRP, blood cultures if febrile

5 · IV antibiotics

Grade I/II: cefuroxime 1.5g IV TDS + metronidazole 500mg IV TDS
Grade III or septic: piperacillin-tazobactam 4.5g IV Q8h
Switch to oral when tolerating diet and apyrexial for 24h

6 · Surgical intervention

Grade I/II: early laparoscopic cholecystectomy within 72h (reduced complications vs delayed)
Grade III / poor surgical candidate: percutaneous cholecystostomy (drain under USS/CT guidance) as bridge
ERCP: if choledocholithiasis suspected (dilated CBD on USS, rising LFTs/bilirubin/ALP)

7 · Special considerations

Emphysematous cholecystitis: gas in gallbladder wall on CT — diabetic patients, emergency cholecystectomy
Mirizzi syndrome: gallstone compressing common hepatic duct — complex ERCP or surgery
Acalculous cholecystitis: critically ill patients (ICU); diagnose on USS, treat with cholecystostomy

Drugs

Drug	Dose	Route	Notes
Cefuroxime	1.5g	IV	TDS. First-line for Grade I/II cholecystitis.
Metronidazole	500mg	IV	TDS for anaerobic cover. Combine with cefuroxime.
Piperacillin-tazobactam	4.5g	IV	Q8h. For Grade III / septic cholecystitis.
Morphine	5–10mg	IV	Titrate to pain. Safe in biliary colic/cholecystitis — does not worsen Sphincter of Oddi spasm significantly.
Diclofenac	75mg	IM	Pre-operatively or for biliary colic. Avoid in AKI or eGFR <30.

When to escalate

Grade III Tokyo (organ dysfunction) — ITU/HDU involvement, percutaneous cholecystostomy,Gallbladder perforation on imaging — emergency surgical referral,Emphysematous cholecystitis (gas on CT) — emergency cholecystectomy,Mirizzi syndrome — complex ERCP or hepatobiliary surgical referral,Failure of conservative management at 72h — surgical reassessment

Reference: Tokyo Guidelines 2018 (TG18) / NICE CG188 Gallstone Disease

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