PURPOSE

• aid diagnosis and treatment for acute cholecystitis

 DIAGNOSTIC CRITERIA

A. Local signs of inflammation

1. Murphy’s sign
2. RUQ mass/pain/temderness

B. Systemic signs of inflammation etc

3. Fever
4. Elevated CRP
5. Elevated WBC count
C.
Imaging findings characteristic of acute cholecystitis
 DIAGNOSTIC CRITERIA

A. Local signs of inflammation

Imaging findings
1. Murphy’s sign characteristic of acute cholecystitis
2. RUQ mass/pain/temderness
• Thickening of the Gallbladder wall (5 mm or greater)
• Gallbladder enlargement
B. Systemic signs of inflammation etc
• Debris echo
3. Fever
• Ultrasonographic
4. Elevated CRP Murphy’s sign (Direct tenderness that occurs when
the
5. probe is WBC
Elevated pushed against the gallbladder)
count
• Gas imaging
C.
• Pericholecystic fluid
Imaging findings characteristic of acute cholecystitis
SUSPECTED DIAGNOSIS
One item in A + one item in B

DEFINITE DIAGNOSIS
One item in A + one item in B+C
EXCLUSION
• Acute hepatitis
• Other acute abdominal diseases
• Chronic cholecystitis
 SEVERITY ASSESSMENT

• Grade III (Severe)

• Grade II (Moderate)
• Grade I (Mild)
 SEVERITY ASSESSMENT

Grade III (Severe)

Grade III” acute cholecystitis is associated with dysfunction of any one of the
following organs/systems

1. Cardiovascular dysfunction: Hypotension requiring treatment with

dopamine ≥5 μg/kg per min, or any dose of norepinephrine
2. Neurological dysfunction: Decreased level of consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio <300
4. Renal dysfunction: Oliguria, Creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT‐INR >1.5
6. Hematological dysfunction: Platelet count <100,000/mm3
 SEVERITY ASSESSMENT

Grade II (Moderate)
“Grade II” acute cholecystitis is associated with any one of the following
conditions:

1. Elevated WBC count (>18,000/mm3)

2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess,
hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
 SEVERITY ASSESSMENT

Grade I (Mild)
“Grade I” acute cholecystitis does not meet the criteria of “Grade III”
or “Grade II” acute cholecystitis.

Acute cholecystitis in a healthy patient with no organ dysfunction

and mild inflammatory changes in the gallbladder
MANAGEMENT
 CHARLSON
COMORBIDITY
INDEX
 AMERICAN SOCIETY OF ANESTHESIOLOGISTS
PHYSICAL STATUS CLASSIFICATION SYSTEM (ASA-PS)
Λ- CCI 5 or less and/or ASA class II or less (low risk);
µ- CCI 6 or greater and/or ASA class III or greater (not low risk);
▵- in case of serious operative difficulty, bail‐out procedures
including conversion should be used
α, antibiotics and general supportive care successful
ϕ, antibiotics and general supportive care fail to control inflammation
λ, CCI 5 or less and/or ASA ‐PS class II or less (low risk)
µ, CCI 6 or greater and/or ASA ‐PS class III or greater (not low risk);
※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics
†, a bile culture should be performed during GB drainage
▵, in case of serious operative difficulty, bail‐out procedures including conversion should be used
※ - performance of a blood culture should be taken into consideration before initiation of administration of antibiotics;
# - negative predictive factors: jaundice (TB il ≥2), neurological dysfunction, respiratory dysfunction;
Φ - FOSF : favorable organ system failure = cardiovascular or renal organ system failure which is rapidly reversible after
admission and before early LC in AC ;
* - in cases of Grade III , CCI (Charlson comorbidity index) 4 or greater, ASA ‐PS 3 or greater are high risk;
† - a bile culture should be performed during GB drainage;
Ψ - advanced center = intensive care and advanced laparoscopic techniques are available;
▵- in case of serious operative difficulty, bail‐out procedures including conversion should be used.
 MANAGEMENT BUNDLE FOR ACUTE
CHOLECYSTITIS

1. Perform a diagnostic assessment every 6 to 12 h

2. Perform abdominal US, followed by a CT scan or HIDA scan if needed

3. Use the severity assessment criteria to assess severity repeatedly:

 MANAGEMENT BUNDLE FOR ACUTE
CHOLECYSTITIS

1. Perform a diagnostic assessment every 6 to 12 h

 at diagnosis
2. Perform abdominal US, followed by a CT scan or HIDA scan if needed
 within
to make 24 h after diagnosis
a diagnosis
 and from 24 to 48 h after diagnosis
3. Use the severity assessment criteria to assess severity repeatedly:
 MANAGEMENT BUNDLE FOR ACUTE
CHOLECYSTITIS

4. Taking into consideration the need for cholecystectomy.

5. In Grade I (mild) patients, Lap‐C at an early stage of onset of symptoms is

recommended

6. If conservative treatment is selected for patients with Grade I (mild)

disease and no response to initial treatment is observed within 24 h,
reconsider early Lap‐C if patient performance status is good and fewer
than 7 days have passed since symptom onset or biliary tract drainage.
 MANAGEMENT BUNDLE FOR ACUTE
CHOLECYSTITIS

7. In Grade II (moderate)

Urgent/early Lap‐C  patient performance status is good and the advanced

Lap‐C technique is available

Urgent/early biliary drainage, or delayed/elective Lap‐C If the patient’s

condition is poor
 MANAGEMENT BUNDLE FOR ACUTE
CHOLECYSTITIS

8. In Grade III (severe) patients with high surgical risk*, perform urgent/early biliary
drainage. If there are neither negative predictive factors** nor FOSF***and the
patient has good PS, early Lap‐C at an advanced center can be chosen.
9. Perform blood culture or bile culture, or both, in Grade II (moderate) and III
(severe) patients.
10. Consider transferring the patient to advanced facilities if urgent/emergency Lap‐
C, biliary drainage, and intensive care are not available.
CRITERIA FOR TRANSFER TO AN “ADVANCED
CENTER”

• SEVERE ACUTE CHOLECYSTITIS (GRADE III)

When a patient meets certain conditions defined by the AC flowchart, Lap‐
C can be performed only by an expert laparoscopic surgeon at a specialized
center that provides intensive care. Otherwise, transfer to advanced facilities
should be considered
CRITERIA FOR TRANSFER TO AN “ADVANCED
CENTER”

• MODERATE ACUTE CHOLECYSTITIS (GRADE II)

Patients should be treated at centers that can provide emergent drainage
of the gallbladder or early Lap‐C. Otherwise, transfer to advanced facilities
should be considered

• MILD ACUTE CHOLECYSTITIS (GRADE I)

In the case of patients whose operation is delayed because of existing
serious comorbidity transfer to advanced facilities that can provide emergent
drainage of the gallbladder or early Lap‐C should be considered
Thank
you