Tokyo Guidelines for Acute Cholecystitis 2018
Provides diagnostic criteria and severity grading for acute cholecystitis.
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If a definitive diagnosis cannot be made on presentation, it is reasonable to reassess the patient using the diagnostic criteria every 6-12 hours.
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Early LC in 3-7 days is recommended for low risk candidates.
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For high risk candidates, percutaneous transhepatic gallbladder drainage should be considered. Endoscopic drainage (either via EUS or ERCP) can be considered in high volume centers.
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Antibiotics should be chosen based on severity of disease, location of infection (community or hospital acquired), and local susceptibilities (see Tokyo Guidelines 2018 Antimicrobial Therapy for Acute Cholangitis and Cholecystitis).
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Grade I (mild):
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Grade II (moderate):
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LC should ideally be performed early after onset of symptoms for low risk patients based on the CCI and ASA scores, preferably in a high volume center.
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In high risk patients (CCI ≥6, ASA ≥3), gallbladder drainage should be considered early with delayed/elective LC.
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Grade III (severe):
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Resuscitative measures should be initiated at first with antibiotics, fluid resuscitation and vasopressor/respiratory support as needed.
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When considering LC, note negative predictive factors of neurological dysfunction, respiratory dysfunction, and co-existence of jaundice (total bilirubin ≥2 mg/dL). In addition, scores of CCI ≥4 and ASA ≥3 suggest high risk for LC.
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If an adequate clinical response is achieved in low risk patients, early LC can be considered in a high volume expert center.
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In high risk patients, or all patients in low volume centers, early gallbladder drainage is recommended, especially if it is not possible to control gallbladder inflammation with initial treatment.