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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines</title><author><name sortKey="Hirota, Masahiko" sort="Hirota, Masahiko" uniqKey="Hirota M" first="Masahiko" last="Hirota">Masahiko Hirota</name><affiliation><nlm:aff id="A1">Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto, 860-8556 Japan</nlm:aff></affiliation></author><author><name sortKey="Takada, Tadahiro" sort="Takada, Tadahiro" uniqKey="Takada T" first="Tadahiro" last="Takada">Tadahiro Takada</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Kawarada, Yoshifumi" sort="Kawarada, Yoshifumi" uniqKey="Kawarada Y" first="Yoshifumi" last="Kawarada">Yoshifumi Kawarada</name><affiliation><nlm:aff id="A3">Mie University School of Medicine, Mie, Japan</nlm:aff></affiliation></author><author><name sortKey="Nimura, Yuji" sort="Nimura, Yuji" uniqKey="Nimura Y" first="Yuji" last="Nimura">Yuji Nimura</name><affiliation><nlm:aff id="A4">Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan</nlm:aff></affiliation></author><author><name sortKey="Miura, Fumihiko" sort="Miura, Fumihiko" uniqKey="Miura F" first="Fumihiko" last="Miura">Fumihiko Miura</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Hirata, Koichi" sort="Hirata, Koichi" uniqKey="Hirata K" first="Koichi" last="Hirata">Koichi Hirata</name><affiliation><nlm:aff id="A5">First Department of Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan</nlm:aff></affiliation></author><author><name sortKey="Mayumi, Toshihiko" sort="Mayumi, Toshihiko" uniqKey="Mayumi T" first="Toshihiko" last="Mayumi">Toshihiko Mayumi</name><affiliation><nlm:aff id="A6">Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine, Nagoya, Japan</nlm:aff></affiliation></author><author><name sortKey="Yoshida, Masahiro" sort="Yoshida, Masahiro" uniqKey="Yoshida M" first="Masahiro" last="Yoshida">Masahiro Yoshida</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Strasberg, Steven" sort="Strasberg, Steven" uniqKey="Strasberg S" first="Steven" last="Strasberg">Steven Strasberg</name><affiliation><nlm:aff id="A7">Department of Surgery, Indiana University School of Medicine, Indianapolis, USA</nlm:aff></affiliation></author><author><name sortKey="Pitt, Henry" sort="Pitt, Henry" uniqKey="Pitt H" first="Henry" last="Pitt">Henry Pitt</name><affiliation><nlm:aff id="A8">Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital, St Louis, USA</nlm:aff></affiliation></author><author><name sortKey="Gadacz, Thomas R" sort="Gadacz, Thomas R" uniqKey="Gadacz T" first="Thomas R" last="Gadacz">Thomas R. Gadacz</name><affiliation><nlm:aff id="A9">Department of Gastrointestinal Surgery, Medical College of Georgia, Georgia, USA</nlm:aff></affiliation></author><author><name sortKey="De Santibanes, Eduardo" sort="De Santibanes, Eduardo" uniqKey="De Santibanes E" first="Eduardo" last="De Santibanes">Eduardo De Santibanes</name><affiliation><nlm:aff id="A10">Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina</nlm:aff></affiliation></author><author><name sortKey="Gouma, Dirk J" sort="Gouma, Dirk J" uniqKey="Gouma D" first="Dirk J." last="Gouma">Dirk J. Gouma</name><affiliation><nlm:aff id="A11">Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Solomkin, Joseph S" sort="Solomkin, Joseph S" uniqKey="Solomkin J" first="Joseph S." last="Solomkin">Joseph S. Solomkin</name><affiliation><nlm:aff id="A12">Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, USA</nlm:aff></affiliation></author><author><name sortKey="Belghiti, Jacques" sort="Belghiti, Jacques" uniqKey="Belghiti J" first="Jacques" last="Belghiti">Jacques Belghiti</name><affiliation><nlm:aff id="A13">Department of Digestive Surgery and Transplantation, Hospital Beaujon, Clichy, France</nlm:aff></affiliation></author><author><name sortKey="Neuhaus, Horst" sort="Neuhaus, Horst" uniqKey="Neuhaus H" first="Horst" last="Neuhaus">Horst Neuhaus</name><affiliation><nlm:aff id="A14">Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany</nlm:aff></affiliation></author><author><name sortKey="Buchler, Markus W" sort="Buchler, Markus W" uniqKey="Buchler M" first="Markus W." last="Büchler">Markus W. Büchler</name><affiliation><nlm:aff id="A15">Department of Surgery, University of Heidelberg, Heidelberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Fan, Sheung Tat" sort="Fan, Sheung Tat" uniqKey="Fan S" first="Sheung-Tat" last="Fan">Sheung-Tat Fan</name><affiliation><nlm:aff id="A16">Department of Surgery, The University of Hong Kong, Hong Kong, China</nlm:aff></affiliation></author><author><name sortKey="Ker, Chen Guo" sort="Ker, Chen Guo" uniqKey="Ker C" first="Chen-Guo" last="Ker">Chen-Guo Ker</name><affiliation><nlm:aff id="A17">Division of HPB Surgery, Yuan’s General Hospital, Taoyuan, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Padbury, Robert T" sort="Padbury, Robert T" uniqKey="Padbury R" first="Robert T." last="Padbury">Robert T. Padbury</name><affiliation><nlm:aff id="A18">Division of Surgical and Specialty Services, Flinders Medical Centre, Adelaide, Australia</nlm:aff></affiliation></author><author><name sortKey="Liau, Kui Hin" sort="Liau, Kui Hin" uniqKey="Liau K" first="Kui-Hin" last="Liau">Kui-Hin Liau</name><affiliation><nlm:aff id="A19">Department of Surgery, Tan Tock Seng Hospital / Hepatobiliary Surgery, Medical Centre, Singapore, Singapore</nlm:aff></affiliation></author><author><name sortKey="Hilvano, Serafin C" sort="Hilvano, Serafin C" uniqKey="Hilvano S" first="Serafin C." last="Hilvano">Serafin C. Hilvano</name><affiliation><nlm:aff id="A20">Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines</nlm:aff></affiliation></author><author><name sortKey="Belli, Giulio" sort="Belli, Giulio" uniqKey="Belli G" first="Giulio" last="Belli">Giulio Belli</name><affiliation><nlm:aff id="A21">Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy</nlm:aff></affiliation></author><author><name sortKey="Windsor, John A" sort="Windsor, John A" uniqKey="Windsor J" first="John A." last="Windsor">John A. Windsor</name><affiliation><nlm:aff id="A22">Department of Surgery, The University of Auckland, Auckland, New Zealand</nlm:aff></affiliation></author><author><name sortKey="Dervenis, Christos" sort="Dervenis, Christos" uniqKey="Dervenis C" first="Christos" last="Dervenis">Christos Dervenis</name><affiliation><nlm:aff id="A23">First Department of Surgery, Agia Olga Hospital, Athens, Greece</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">17252300</idno><idno type="pmc">2784516</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784516</idno><idno type="RBID">PMC:2784516</idno><idno type="doi">10.1007/s00534-006-1159-4</idno><date when="2007">2007</date><idno type="wicri:Area/Pmc/Corpus">001147</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001147</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines</title><author><name sortKey="Hirota, Masahiko" sort="Hirota, Masahiko" uniqKey="Hirota M" first="Masahiko" last="Hirota">Masahiko Hirota</name><affiliation><nlm:aff id="A1">Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto, 860-8556 Japan</nlm:aff></affiliation></author><author><name sortKey="Takada, Tadahiro" sort="Takada, Tadahiro" uniqKey="Takada T" first="Tadahiro" last="Takada">Tadahiro Takada</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Kawarada, Yoshifumi" sort="Kawarada, Yoshifumi" uniqKey="Kawarada Y" first="Yoshifumi" last="Kawarada">Yoshifumi Kawarada</name><affiliation><nlm:aff id="A3">Mie University School of Medicine, Mie, Japan</nlm:aff></affiliation></author><author><name sortKey="Nimura, Yuji" sort="Nimura, Yuji" uniqKey="Nimura Y" first="Yuji" last="Nimura">Yuji Nimura</name><affiliation><nlm:aff id="A4">Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan</nlm:aff></affiliation></author><author><name sortKey="Miura, Fumihiko" sort="Miura, Fumihiko" uniqKey="Miura F" first="Fumihiko" last="Miura">Fumihiko Miura</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Hirata, Koichi" sort="Hirata, Koichi" uniqKey="Hirata K" first="Koichi" last="Hirata">Koichi Hirata</name><affiliation><nlm:aff id="A5">First Department of Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan</nlm:aff></affiliation></author><author><name sortKey="Mayumi, Toshihiko" sort="Mayumi, Toshihiko" uniqKey="Mayumi T" first="Toshihiko" last="Mayumi">Toshihiko Mayumi</name><affiliation><nlm:aff id="A6">Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine, Nagoya, Japan</nlm:aff></affiliation></author><author><name sortKey="Yoshida, Masahiro" sort="Yoshida, Masahiro" uniqKey="Yoshida M" first="Masahiro" last="Yoshida">Masahiro Yoshida</name><affiliation><nlm:aff id="A2">Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</nlm:aff></affiliation></author><author><name sortKey="Strasberg, Steven" sort="Strasberg, Steven" uniqKey="Strasberg S" first="Steven" last="Strasberg">Steven Strasberg</name><affiliation><nlm:aff id="A7">Department of Surgery, Indiana University School of Medicine, Indianapolis, USA</nlm:aff></affiliation></author><author><name sortKey="Pitt, Henry" sort="Pitt, Henry" uniqKey="Pitt H" first="Henry" last="Pitt">Henry Pitt</name><affiliation><nlm:aff id="A8">Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital, St Louis, USA</nlm:aff></affiliation></author><author><name sortKey="Gadacz, Thomas R" sort="Gadacz, Thomas R" uniqKey="Gadacz T" first="Thomas R" last="Gadacz">Thomas R. Gadacz</name><affiliation><nlm:aff id="A9">Department of Gastrointestinal Surgery, Medical College of Georgia, Georgia, USA</nlm:aff></affiliation></author><author><name sortKey="De Santibanes, Eduardo" sort="De Santibanes, Eduardo" uniqKey="De Santibanes E" first="Eduardo" last="De Santibanes">Eduardo De Santibanes</name><affiliation><nlm:aff id="A10">Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina</nlm:aff></affiliation></author><author><name sortKey="Gouma, Dirk J" sort="Gouma, Dirk J" uniqKey="Gouma D" first="Dirk J." last="Gouma">Dirk J. Gouma</name><affiliation><nlm:aff id="A11">Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Solomkin, Joseph S" sort="Solomkin, Joseph S" uniqKey="Solomkin J" first="Joseph S." last="Solomkin">Joseph S. Solomkin</name><affiliation><nlm:aff id="A12">Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, USA</nlm:aff></affiliation></author><author><name sortKey="Belghiti, Jacques" sort="Belghiti, Jacques" uniqKey="Belghiti J" first="Jacques" last="Belghiti">Jacques Belghiti</name><affiliation><nlm:aff id="A13">Department of Digestive Surgery and Transplantation, Hospital Beaujon, Clichy, France</nlm:aff></affiliation></author><author><name sortKey="Neuhaus, Horst" sort="Neuhaus, Horst" uniqKey="Neuhaus H" first="Horst" last="Neuhaus">Horst Neuhaus</name><affiliation><nlm:aff id="A14">Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany</nlm:aff></affiliation></author><author><name sortKey="Buchler, Markus W" sort="Buchler, Markus W" uniqKey="Buchler M" first="Markus W." last="Büchler">Markus W. Büchler</name><affiliation><nlm:aff id="A15">Department of Surgery, University of Heidelberg, Heidelberg, Germany</nlm:aff></affiliation></author><author><name sortKey="Fan, Sheung Tat" sort="Fan, Sheung Tat" uniqKey="Fan S" first="Sheung-Tat" last="Fan">Sheung-Tat Fan</name><affiliation><nlm:aff id="A16">Department of Surgery, The University of Hong Kong, Hong Kong, China</nlm:aff></affiliation></author><author><name sortKey="Ker, Chen Guo" sort="Ker, Chen Guo" uniqKey="Ker C" first="Chen-Guo" last="Ker">Chen-Guo Ker</name><affiliation><nlm:aff id="A17">Division of HPB Surgery, Yuan’s General Hospital, Taoyuan, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Padbury, Robert T" sort="Padbury, Robert T" uniqKey="Padbury R" first="Robert T." last="Padbury">Robert T. Padbury</name><affiliation><nlm:aff id="A18">Division of Surgical and Specialty Services, Flinders Medical Centre, Adelaide, Australia</nlm:aff></affiliation></author><author><name sortKey="Liau, Kui Hin" sort="Liau, Kui Hin" uniqKey="Liau K" first="Kui-Hin" last="Liau">Kui-Hin Liau</name><affiliation><nlm:aff id="A19">Department of Surgery, Tan Tock Seng Hospital / Hepatobiliary Surgery, Medical Centre, Singapore, Singapore</nlm:aff></affiliation></author><author><name sortKey="Hilvano, Serafin C" sort="Hilvano, Serafin C" uniqKey="Hilvano S" first="Serafin C." last="Hilvano">Serafin C. Hilvano</name><affiliation><nlm:aff id="A20">Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines</nlm:aff></affiliation></author><author><name sortKey="Belli, Giulio" sort="Belli, Giulio" uniqKey="Belli G" first="Giulio" last="Belli">Giulio Belli</name><affiliation><nlm:aff id="A21">Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy</nlm:aff></affiliation></author><author><name sortKey="Windsor, John A" sort="Windsor, John A" uniqKey="Windsor J" first="John A." last="Windsor">John A. Windsor</name><affiliation><nlm:aff id="A22">Department of Surgery, The University of Auckland, Auckland, New Zealand</nlm:aff></affiliation></author><author><name sortKey="Dervenis, Christos" sort="Dervenis, Christos" uniqKey="Dervenis C" first="Christos" last="Dervenis">Christos Dervenis</name><affiliation><nlm:aff id="A23">First Department of Surgery, Agia Olga Hospital, Athens, Greece</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Hepato-Biliary-Pancreatic Surgery</title><idno type="ISSN">0944-1166</idno><idno type="eISSN">1436-0691</idno><imprint><date when="2007">2007</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy’s sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc xml:lang="EN" article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Hepatobiliary Pancreat Surg</journal-id><journal-title>Journal of Hepato-Biliary-Pancreatic Surgery</journal-title><issn pub-type="ppub">0944-1166</issn><issn pub-type="epub">1436-0691</issn><publisher><publisher-name>Springer-Verlag</publisher-name><publisher-loc>Tokyo</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">17252300</article-id><article-id pub-id-type="pmc">2784516</article-id><article-id pub-id-type="publisher-id">1159</article-id><article-id pub-id-type="doi">10.1007/s00534-006-1159-4</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name name-style="western"><surname>Hirota</surname><given-names>Masahiko</given-names></name><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Takada</surname><given-names>Tadahiro</given-names></name><xref ref-type="aff" rid="A2"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Kawarada</surname><given-names>Yoshifumi</given-names></name><xref ref-type="aff" rid="A3"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Nimura</surname><given-names>Yuji</given-names></name><xref ref-type="aff" rid="A4"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Miura</surname><given-names>Fumihiko</given-names></name><xref ref-type="aff" rid="A2"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Hirata</surname><given-names>Koichi</given-names></name><xref ref-type="aff" rid="A5"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Mayumi</surname><given-names>Toshihiko</given-names></name><xref ref-type="aff" rid="A6"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Yoshida</surname><given-names>Masahiro</given-names></name><xref ref-type="aff" rid="A2"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Strasberg</surname><given-names>Steven</given-names></name><xref ref-type="aff" rid="A7"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Pitt</surname><given-names>Henry</given-names></name><xref ref-type="aff" rid="A8"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Gadacz</surname><given-names>Thomas R</given-names></name><xref ref-type="aff" rid="A9"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>de Santibanes</surname><given-names>Eduardo</given-names></name><xref ref-type="aff" rid="A10"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Gouma</surname><given-names>Dirk J.</given-names></name><xref ref-type="aff" rid="A11"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Solomkin</surname><given-names>Joseph S.</given-names></name><xref ref-type="aff" rid="A12"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Belghiti</surname><given-names>Jacques</given-names></name><xref ref-type="aff" rid="A13"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Neuhaus</surname><given-names>Horst</given-names></name><xref ref-type="aff" rid="A14"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Büchler</surname><given-names>Markus W.</given-names></name><xref ref-type="aff" rid="A15"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Fan</surname><given-names>Sheung-Tat</given-names></name><xref ref-type="aff" rid="A16"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Ker</surname><given-names>Chen-Guo</given-names></name><xref ref-type="aff" rid="A17"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Padbury</surname><given-names>Robert T.</given-names></name><xref ref-type="aff" rid="A18"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Liau</surname><given-names>Kui-Hin</given-names></name><xref ref-type="aff" rid="A19"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Hilvano</surname><given-names>Serafin C.</given-names></name><xref ref-type="aff" rid="A20"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Belli</surname><given-names>Giulio</given-names></name><xref ref-type="aff" rid="A21"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Windsor</surname><given-names>John A.</given-names></name><xref ref-type="aff" rid="A22"></xref></contrib><contrib contrib-type="author"><name name-style="western"><surname>Dervenis</surname><given-names>Christos</given-names></name><xref ref-type="aff" rid="A23"></xref></contrib><aff id="A1"><label></label>Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto, 860-8556 Japan</aff><aff id="A2"><label></label>Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan</aff><aff id="A3"><label></label>Mie University School of Medicine, Mie, Japan</aff><aff id="A4"><label></label>Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan</aff><aff id="A5"><label></label>First Department of Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan</aff><aff id="A6"><label></label>Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine, Nagoya, Japan</aff><aff id="A7"><label></label>Department of Surgery, Indiana University School of Medicine, Indianapolis, USA</aff><aff id="A8"><label></label>Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital, St Louis, USA</aff><aff id="A9"><label></label>Department of Gastrointestinal Surgery, Medical College of Georgia, Georgia, USA</aff><aff id="A10"><label></label>Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina</aff><aff id="A11"><label></label>Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands</aff><aff id="A12"><label></label>Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, USA</aff><aff id="A13"><label></label>Department of Digestive Surgery and Transplantation, Hospital Beaujon, Clichy, France</aff><aff id="A14"><label></label>Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany</aff><aff id="A15"><label></label>Department of Surgery, University of Heidelberg, Heidelberg, Germany</aff><aff id="A16"><label></label>Department of Surgery, The University of Hong Kong, Hong Kong, China</aff><aff id="A17"><label></label>Division of HPB Surgery, Yuan’s General Hospital, Taoyuan, Taiwan</aff><aff id="A18"><label></label>Division of Surgical and Specialty Services, Flinders Medical Centre, Adelaide, Australia</aff><aff id="A19"><label></label>Department of Surgery, Tan Tock Seng Hospital / Hepatobiliary Surgery, Medical Centre, Singapore, Singapore</aff><aff id="A20"><label></label>Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines</aff><aff id="A21"><label></label>Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy</aff><aff id="A22"><label></label>Department of Surgery, The University of Auckland, Auckland, New Zealand</aff><aff id="A23"><label></label>First Department of Surgery, Agia Olga Hospital, Athens, Greece</aff></contrib-group><pub-date pub-type="epub"><day>30</day><month>01</month><year>2007</year></pub-date><pub-date pub-type="ppub"><month>01</month><year>2007</year></pub-date><volume>14</volume><issue>1</issue><fpage>78</fpage><lpage>82</lpage><history><date date-type="received"><day>31</day><month>05</month><year>2006</year></date><date date-type="accepted"><day>06</day><month>08</month><year>2006</year></date></history><permissions><copyright-statement>© Springer-Verlag Tokyo 2007</copyright-statement></permissions><abstract xml:lang="EN"><p>The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy’s sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.</p></abstract><kwd-group><title>Key words</title><kwd>Acute cholecystitis</kwd><kwd>Diagnosis</kwd><kwd>Severity of illness index</kwd><kwd>Guidelines</kwd><kwd>Infection</kwd></kwd-group><custom-meta-wrap><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© Springer-Verlag Tokyo 2007</meta-value></custom-meta></custom-meta-wrap></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Introduction</title><p>Early diagnosis of acute cholecystitis allows prompt treatment and reduces both mortality and morbidity. The accurate diagnosis of typical as well as atypical cases of acute cholecystitis requires specific diagnostic criteria. Acute cholecystitis has a better prognosis than acute cholangitis, but may require immediate management, especially in patients with torsion of the gallbladder and emphysematous, gangrenous, or suppurative cholecystitis. The lack of standard criteria for diagnosis and severity assessment is reflected by the wide range of reported mortality rates in the literature, and this lack makes it impossible to provide standardized optimal treatment guidelines for patients. In these Guidelines we propose specific criteria for the diagnosis and severity assessment of acute cholecystitis, based on the best available evidence and the experts’ consensus achieved at the International Consensus Meeting for the Management of Acute Cholecystitis and Cholangitis, held on April 1–2, 2006, in Tokyo.</p></sec><sec id="Sec2"><title>Diagnostic criteria for acute cholecystitis</title><p>Diagnosis is the starting point of the management of acute cholecystitis, and prompt and timely diagnosis should lead to early treatment and lower mortality and morbidity. Specific diagnostic criteria are necessary to accurately diagnose typical, as well as atypical cases. The Guidelines propose diagnostic criteria for acute cholecystitis (Table <xref rid="Tab1" ref-type="table">1</xref>). C-reactive protein (CRP) is not commonly measured in many countries. However, because acute cholecystitis is usually associatied with an elevation of CRP level by 3 mg/dl or more, CRP was included. Diagnosis of acute cholecystitis by elevation of CRP level (3 mg/dl or more), with ultrasonographic findings suggesting acute cholecystitis, has a sensitivity of 97%, specificity of 76%, and positive predictive value of 95% (level 1b).<xref ref-type="bibr" rid="CR1">1</xref> After the discussion during the Tokyo International Consensus Meeting, almost unanimous agreement was achieved on the criteria (Table <xref rid="Tab2" ref-type="table">2</xref>). However, 19% of the panelists from abroad expressed the necessity for minor modifications, because, in the provisional version, the diagnostic criteria did not include technetium hepatobiliery iminodiacetic acid (Tc-HIDA) scan as an item. <table-wrap id="Tab1"><label>Table 1</label><caption><p>Diagnostic criteria for acute cholecystitis</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>A. Local signs of inflammation etc.:</td></tr><tr><td>(1) Murphy’s sign, (2) RUQ mass/pain/tenderness</td></tr><tr><td>B. Systemic signs of inflammation etc.:</td></tr><tr><td>(1) Fever, (2) elevated CRP, (3) elevated WBC count</td></tr><tr><td>C. Imaging findings: imaging findings characteristic of acute cholecystitis</td></tr><tr><td>Definite diagnosis</td></tr><tr><td>(1) One item in A and one item in B are positive</td></tr><tr><td>(2) C confirms the diagnosis when acute cholecystitis is suspected clinically</td></tr></tbody></table><table-wrap-foot><p>Note: acute hepatitis, other acute abdominal diseases, and chronic cholecystitis should be excluded</p></table-wrap-foot></table-wrap><table-wrap id="Tab2"><label>Table 2</label><caption><p>Answer pad responses on the diagnostic criteria for acute cholecystitis</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Agree</th><th>Agree, but needs minor modifications</th><th>Disagree</th></tr></thead><tbody><tr><td>Total (<italic>n</italic> = 110)</td><td>92%</td><td>8%</td><td>0%</td></tr><tr><td>Panelists from abroad (<italic>n</italic> = 21)</td><td>81%</td><td>19%</td><td>0</td></tr><tr><td>Japanese panelists (<italic>n</italic> = 20)</td><td>100%</td><td>0%</td><td>0%</td></tr><tr><td>Audience (<italic>n</italic> = 69)</td><td>93%</td><td>7%</td><td>0%</td></tr></tbody></table></table-wrap></p><sec id="Sec3"><title>Imaging findings of acute cholecystitis</title><p><list list-type="bullet"><list-item><p>Ultrasonography findings (level 4)<xref ref-type="bibr" rid="CR2">2</xref>–<xref ref-type="bibr" rid="CR5">5</xref><list list-type="bullet"><list-item><p>Sonographic Murphy sign (tenderness elicited by pressing the gallbladder with the ultrasound probe)</p></list-item><list-item><p>Thickened gallbladder wall (>4 mm; if the patient does not have chronic liver disease and/or ascites or right heart failure)</p></list-item><list-item><p>Enlarged gallbladder (long axis diameter >8 cm, short axis diameter >4 cm)</p></list-item><list-item><p>Incarcerated gallstone, debris echo, pericholecystic fluid collection</p></list-item><list-item><p>Sonolucent layer in the gallbladder wall, striated intramural lucencies, and Doppler signals.</p></list-item></list></p></list-item><list-item><p>Magnetic resonance imaging (MRI) findings (level 1b–4)}<xref ref-type="bibr" rid="CR6">6</xref>–<xref ref-type="bibr" rid="CR9">9</xref><list list-type="bullet"><list-item><p>Pericholecystic high signal</p></list-item><list-item><p>Enlarged gallbladder</p></list-item><list-item><p>Thickened gallbladder wall.</p></list-item></list></p></list-item><list-item><p>Computed tomography (CT) findings (level 3b)<xref ref-type="bibr" rid="CR10">10</xref><list list-type="bullet"><list-item><p>Thickened gallbladder wall</p></list-item><list-item><p>Pericholecystic fluid collection</p></list-item><list-item><p>Enlarged gallbladder Linear high-density areas in the pericholecystic fat tissue.</p></list-item></list></p></list-item><list-item><p>Tc-HIDA scans (level 4)<xref ref-type="bibr" rid="CR11">11</xref>,<xref ref-type="bibr" rid="CR12">12</xref><list list-type="bullet"><list-item><p>Non-visualized gallbladder with normal uptake and excretion of radioactivity</p></list-item><list-item><p>Rim sign (augmentation of radioactivity around the gallbladder fossa).</p></list-item></list></p></list-item></list></p></sec></sec><sec id="Sec4"><title>Severity assessment criteria of acute cholecystitis</title><sec id="Sec5"><title>Concept of severity grading of acute cholecystitis</title><p>Patients with acute cholecystitis may present with a spectrum of disease stages ranging from a mild, self-limited illness to a fulminant, potentially life-threatening illness. In these Guidelines we classify the severity of acute cholecystitis into the following three categories: “mild (grade I)”, “moderate (grade II)”, and “severe (grade III)”. A category for the most severe grade of acute cholecystitis is needed because this grade requires intensive care and urgent treatment (operation and/or drainage) to save the patient’s life. However, the vast majority of patients present with less severe forms of the disease. In these patients, the major practical question regarding management is whether it is advisable to perform cholecystectomy at the time of presentation in the acute phase or whether other strategies of management should be chosen during the acute phase, followed by an interval cholecystectomy. Therefore, to guide the clinician, the severity grading includes a “moderate” group based on criteria predicting when conditions might be unfavorable for cholecystectomy in the acute phase (level 2b–4).<xref ref-type="bibr" rid="CR13">13</xref>–<xref ref-type="bibr" rid="CR18">18</xref> Patients who fall neither into the severe nor the moderate group form the majority of patients with this disease; their disease is suitable for management by cholecystectomy in the acute phase, if comorbidities are not a factor. Definitions of the three grades are given below.</p></sec><sec id="Sec6"><title>Mild (grade I) acute cholecystitis</title><p>Mild acute cholecystitis occurs in a patient in whom there are no findings of organ dysfunction, and there is mild disease in the gallbladder, allowing for cholecystectomy to be performed as a safe and low-risk procedure. These patients do not have a severity index that meets the criteria for “moderate (grade II)” or “severe (grade III)” acute cholecystitis.</p></sec><sec id="Sec7"><title>Moderate (grade II) acute cholecystitis</title><p>In moderate acute cholecystitis, the degree of acute inflammation is likely to be associated with increased operative difficulty to perform a cholecystectomy (level 2b–4).<xref ref-type="bibr" rid="CR13">13</xref>–<xref ref-type="bibr" rid="CR18">18</xref></p></sec><sec id="Sec8"><title>Severe (grade III) acute cholecystitis</title><p>Severe acute cholecystitis is associated with organ dysfunction.</p></sec><sec id="Sec9"><title>Criteria for the severity assessment of acute cholecystitis</title><p>Acute cholecystitis has a better outcome/prognosis than acute cholangitis but requires prompt treatment if gangrenous cholecystitis, emphysematous cholecystitis, or torsion of the gallbladder are present. The progression of acute cholecystitis from the mild/moderate to the severe form means the development of the multiple organ dysfunction syndrome (MODS). Organ dysfunction scores, such as Marshall’s multiple organ dysfunction (MOD) score, and the sequential organ failure assessment (SOFA) score, are sometimes used to evaluate organ dysfunction in critically ill patients. The Guidelines classify the severity of acute cholecystitis into three grades (Tables <xref rid="Tab3" ref-type="table">3</xref>–<xref rid="Tab5" ref-type="table">5</xref>): “severe (grade III)”: acute cholecystitis associated with organ dysfunction, “moderate (grade II)”: acute cholecystitis associated with difficulty to perform cholecystectomy due to local inflammation, and “mild (grade I)”: acute cholecystitis which does not meet the criteria of “severe” or “moderate” acute cholecystitis (these patients have acute cholecystitis but no organ dysfunction, and there are mild inflammatory changes in the gallbladder, so that a cholecystectomy can be performed with a low operative risk). Almost unanimous agreement on the criteria was achieved (Tables <xref rid="Tab6" ref-type="table">6</xref> and <xref rid="Tab7" ref-type="table">7</xref>). When acute cholecystitis is accompanied by acute cholangitis, the criteria for the severity assessment of acute cholangitis should also be taken into account. Being “elderly” per se is not a criterion for severity itself, but indicates a propensity to progress to the severe form, and thus is not included in the criteria for severity assessment.
<table-wrap id="Tab3"><label>Table 3</label><caption><p>Criteria for mild (grade I) acute cholecystitis</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>“Mild (grade I)” acute cholecystitis does not meet the criteria of “severe (grade III)” or “moderate (grade II)” acute cholecystitis. Grade I can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and only mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure.</td></tr></tbody></table></table-wrap><table-wrap id="Tab4"><label>Table 4</label><caption><p>Criteria for moderate (grade II) acute cholecystitis</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>“Moderate” acute cholecystitis is accompanied by any one of the following conditions:</td></tr><tr><td>1. Elevated WBC count (>18 000/mm<sup>3</sup>)</td></tr><tr><td>2. Palpable tender mass in the right upper abdominal quadrant</td></tr><tr><td>3. Duration of complaints >72 h<sup>a</sup></td></tr><tr><td>4. Marked local inflammation (biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis)</td></tr></tbody></table><table-wrap-foot><p><sup>a</sup> Laparoscopic surgery in acute cholecystitis should be performed within 96 h after the onset (level 2b-4)<xref ref-type="bibr" rid="CR13">13</xref>,<xref ref-type="bibr" rid="CR14">14</xref>,<xref ref-type="bibr" rid="CR16">16</xref></p></table-wrap-foot></table-wrap><table-wrap id="Tab5"><label>Table 5</label><caption><p>Criteria for severe (grade III) acute cholecystitis</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>“Severe” acute cholecystitis is accompanied by dysfunctions in any one of the following organs/systems</td></tr><tr><td>1. Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≧5 µg/kg per min, or any dose of dobutamine)</td></tr><tr><td>2. Neurological dysfunction (decreased level of consciousness)</td></tr><tr><td>3. Respiratory dysfunction (PaO<sub>2</sub>/FiO<sub>2</sub> ratio <300)</td></tr><tr><td>4. Renal dysfunction (oliguria, creatinine >2.0 mg/dl)</td></tr><tr><td>5. Hepatic dysfunction (PT-INR >1.5)</td></tr><tr><td>6. Hematological dysfunction (platelet count <100 000/mm<sup>3</sup>)</td></tr></tbody></table></table-wrap><table-wrap id="Tab6"><label>Table 6</label><caption><p>Answer pad responses on the criteria for severe (grade III) acute cholecystitis</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Agree</th><th>Agree, but needs minor modifications</th><th>Disagree</th></tr></thead><tbody><tr><td>Total (<italic>n</italic> = 110)</td><td>90%</td><td>10%</td><td>0%</td></tr><tr><td>Panelists from abroad (<italic>n</italic> = 21)</td><td>95%</td><td>5%</td><td>0</td></tr><tr><td>Japanese panelists (<italic>n</italic> = 21)</td><td>81%</td><td>19%</td><td>0%</td></tr><tr><td>Audience (<italic>n</italic> = 68)</td><td>91%</td><td>9%</td><td>0%</td></tr></tbody></table></table-wrap><table-wrap id="Tab7"><label>Table 7</label><caption><p>Answer pad responses on the criteria for moderate (grade II) acute cholecystitis</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Agree</th><th>Agree, but needs minor modifications</th><th>Disagree</th></tr></thead><tbody><tr><td>Total (<italic>n</italic> = 109)</td><td>78%</td><td>22%</td><td>0%</td></tr><tr><td>Panelists from abroad (<italic>n</italic> = 22)</td><td>77%</td><td>23%</td><td>0%</td></tr><tr><td>Japanese panelists (<italic>n</italic> = 22)</td><td>91%</td><td>9%</td><td>0%</td></tr><tr><td>Audience (<italic>n</italic> = 65)</td><td>74%</td><td>26%</td><td>0%</td></tr></tbody></table></table-wrap></p></sec></sec><sec id="Sec10"><title>Discussion at the Tokyo International Consensus Meeting</title><sec id="Sec11"><title>Diagnostic criteria for acute cholecystitis</title><p>The clinical diagnosis of acute cholecystitis is traditionally based on the patient’s clinical presentation, and it is confirmed by the imaging findings. Hence, the initial provisional diagnostic criteria for acute cholecystitis comprised: (1) clinical signs and symptoms, (2) laboratory data, and (3) imaging findings. In the discussion on criteria for “clinical signs and symptoms”, 92% of the Japanese panelists agreed, whereas only 65% of the panelists from abroad agreed and 4% disagreed. In regard to the criteria for “laboratory data”, 20% of the Japanese panelists and 39% of the panelists from abroad voted “agree, but needs minor modifications”. After a discussion among the panelists, several changes were made. In regard to the proposed criteria for “imaging findings”, 66%–71% of the Japanese panelists agreed and about 30% of the panelists voted “agree, but needs minor modifications”, and 4% of the panelists from abroad disagreed, because Tc-HIDA scans were not included. Discussion at the International Consensus Meeting led to the reorganization of these categories as: (1) local signs of inflammation, (2) systemic signs of inflammation, and (3) imaging findings. “Suspected diagnosis” in the provisional criteria was deleted, and two conditions for “definite diagnosis” were established in the final diagnostic criteria. After the discussion, 100% of the Japanese panelists and 81% of the panelists from abroad agreed on the final version (refer to Tables 1 and 2; consensus was reached).</p></sec><sec id="Sec12"><title>Severity assessment criteria for acute cholecystitis</title><p>Concerning criteria for severe (grade III) acute cholecystitis, 81% of the Japanese panelists and 95% of the panelists from abroad agreed with the criteria (refer to Tables <xref rid="Tab5" ref-type="table">5</xref> and <xref rid="Tab6" ref-type="table">6</xref>; consensus was reached). The acute physiology and chronic health evaluation II (APACHE II) score was not included in the assessment criteria, because it is too complicated to apply in community hospitals.</p><p>The criteria for moderate (grade II) acute cholecystitis can be defined as acute cholecystitis associated with local inflammatory conditions that make cholecystectomy difficult (Steven Strasberg, USA; Dirk J. Gouma, the Netherlands; Henry Pitt, USA; Sheung-Tat Fan and Joseph W.Y. Lau, Hong Kong; Serafin C. Hilvano, Philippines). On the basis of these aspects, the final criteria for moderate (grade II) acute cholecystitis were defined and were agreed on by 91% of the Japanese panelists and 77% of those from abroad (refer to Tables <xref rid="Tab4" ref-type="table">4</xref> and <xref rid="Tab7" ref-type="table">7</xref>; consensus was reached).</p><p>The criteria for mild (grade I) acute cholecystitis were agreed on by approximately 90% of both the Japanese panelists and the panelists from abroad (consensus was reached).</p></sec></sec></body><back><ack><title>Acknowledgment</title><p>We would like to express our deep gratitude to the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary-Pancreatic Surgery, who provided us with great support and guidance in the preparation of the Guidelines. 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