Acute Cholecystitis Severity Grading (Tokyo TG18) — free guideline decision tool

This tool grades acute cholecystitis severity (I/II/III) by the Tokyo Guidelines 2018, which links grade to organ dysfunction, local inflammation, and the appropriate management pathway.

Assess Grade III first (any organ dysfunction: cardiovascular/neurologic/respiratory/renal/hepatic/hematologic), then Grade II (WBC > 18,000, tender RUQ mass, duration > 72 h, or marked local inflammation); otherwise Grade I.

Use after diagnosing acute cholecystitis to assign a severity grade and choose between early cholecystectomy, percutaneous cholecystostomy, or organ support with urgent drainage.

Grading is evaluated top-down — rule out Grade III, then Grade II, defaulting to Grade I — so a single organ dysfunction immediately defines severe disease. (original synthesis · not guideline verbatim) This tool grades severity only; the diagnosis itself requires the TG18 triad of local signs, systemic inflammation, and imaging. Surgical timing and approach also weigh anesthetic risk (ASA/CCI) and team experience.

For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.

Inputs: Grade III (severe): any organ dysfunction — cardiovascular (dopamine ≥ 5 or any norepinephrine), neurologic (altered consciousness), respiratory (PaO₂/FiO₂ < 300), renal (oliguria or Cr > 2.0 mg/dL), hepatic (PT-INR > 1.5), hematologic (platelets < 100,000) None, Grade II (moderate): any — WBC > 18,000/µL, palpable tender RUQ mass, duration > 72 h, marked local inflammation (gangrenous/emphysematous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis) None → Result: TG18 grade Grade I (mild)（Grade: Grade I (mild) (assess III first, then II, otherwise I), Management direction: Antimicrobials + early (prompt) laparoscopic cholecystectomy, Note: This tool only grades severity; diagnosing acute cholecystitis requires the TG18 diagnostic criteria (local inflammatory signs + systemic inflammation + imaging). Surgical timing and approach depend on patient status, anesthetic risk (e.g. ASA/CCI), and team conditions） Inputs: Grade III (severe): any organ dysfunction — cardiovascular (dopamine ≥ 5 or any norepinephrine), neurologic (altered consciousness), respiratory (PaO₂/FiO₂ < 300), renal (oliguria or Cr > 2.0 mg/dL), hepatic (PT-INR > 1.5), hematologic (platelets < 100,000) ≥1 present, Grade II (moderate): any — WBC > 18,000/µL, palpable tender RUQ mass, duration > 72 h, marked local inflammation (gangrenous/emphysematous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis) ≥1 present → Result: TG18 grade Grade III (severe)（Grade: Grade III (severe) (assess III first, then II, otherwise I), Management direction: Organ support + urgent biliary drainage/cholecystostomy, manage definitively once stabilized; ICU management, Note: This tool only grades severity; diagnosing acute cholecystitis requires the TG18 diagnostic criteria (local inflammatory signs + systemic inflammation + imaging). Surgical timing and approach depend on patient status, anesthetic risk (e.g. ASA/CCI), and team conditions）