Acute Cholecystitis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] TG18 diagnosis
   Does it meet TG18 (A local inflammation + B systemic inflammation + C imaging)? (A local inflammation: Murphy's sign, RUQ pain/tenderness/mass; B systemic inflammation: fever, raised CRP, raised WBC; C imaging (US/CT/MRCP): gallbladder wall thickening ≥4 mm, distended gallbladder (long axis ≥8 cm/short axis ≥4 cm), stones/debris, pericholecystic fluid. Suspected = A + B; definite = A + B + C.)
   • Suspected / definite cholecystitis → TG18 severity grade
   • Does not meet it → Does not meet it
2. [End] Does not meet it
   Evaluate other causes of RUQ pain (cholangitis, biliary colic, pancreatitis, peptic ulcer, liver abscess, etc.) and manage along the appropriate pathway.
3. [Decision] TG18 severity grade
   TG18 severity grade? (Grade III (severe) = associated organ dysfunction (cardiovascular/neurological/respiratory/renal/hepatic/hematologic). Grade II (moderate) = any of: WBC >18×10⁹, palpable tender mass, duration >72 h, marked local inflammation (gangrenous/emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis). Grade I (mild) = does not meet II/III.)
   • Grade I–II (mild/moderate) → Grade I–II
   • Grade III (severe) → Grade III (severe)
4. [End] Grade I–II
   Antibiotics, fluids, analgesia, support; as long as the patient can tolerate surgery and laparoscopy is available, early laparoscopic cholecystectomy is preferred (regardless of symptom duration; WSES: within 7 days of admission/10 days of onset). For high surgical risk, percutaneous cholecystostomy drainage + antibiotics, with elective surgery later.
5. [End] Grade III (severe)
   Organ support (ICU, vasopressors, etc.), antibiotics, fluids; cholecystectomy if the patient can tolerate it and advanced laparoscopic skills are available, otherwise percutaneous cholecystostomy drainage to control infection + delayed surgery. Multidisciplinary assessment.

Source guidelines & references

• Tokyo Guidelines 2018 (TG18): diagnosis, grading and management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2018
• WSES guideline on acute calculous cholecystitis

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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