Journal of Hepato-Biliary-Pancreatic Surgery

, 14:78

First online:

Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines

  • Masahiko HirotaAffiliated withDepartment of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences
  • , Tadahiro TakadaAffiliated withDepartment of Surgery, Teikyo University School of Medicine
  • , Yoshifumi KawaradaAffiliated withMie University School of Medicine
  • , Yuji NimuraAffiliated withDivision of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine
  • , Fumihiko MiuraAffiliated withDepartment of Surgery, Teikyo University School of Medicine
  • , Koichi HirataAffiliated withFirst Department of Surgery, Sapporo Medical University School of Medicine
  • , Toshihiko MayumiAffiliated withDepartment of Emergency Medicine and Critical Care, Nagoya University School of Medicine
  • , Masahiro YoshidaAffiliated withDepartment of Surgery, Teikyo University School of Medicine
  • , Steven StrasbergAffiliated withDepartment of Surgery, Indiana University School of Medicine
    • , Henry PittAffiliated withDepartment of Surgery, Washington University in St Louis and Barnes-Jewish Hospital
    • , Thomas R GadaczAffiliated withDepartment of Gastrointestinal Surgery, Medical College of Georgia
    • , Eduardo de SantibanesAffiliated withDepartment of Surgery, University of Buenos Aires
    • , Dirk J. GoumaAffiliated withDepartment of Surgery, Academic Medical Center
    • , Joseph S. SolomkinAffiliated withDepartment of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine
    • , Jacques BelghitiAffiliated withDepartment of Digestive Surgery and Transplantation, Hospital Beaujon
    • , Horst NeuhausAffiliated withDepartment of Internal Medicine, Evangelisches Krankenhaus Düsseldorf
    • , Markus W. BüchlerAffiliated withDepartment of Surgery, University of Heidelberg
    • , Sheung-Tat FanAffiliated withDepartment of Surgery, The University of Hong Kong
    • , Chen-Guo KerAffiliated withDivision of HPB Surgery, Yuan’s General Hospital
    • , Robert T. PadburyAffiliated withDivision of Surgical and Specialty Services, Flinders Medical Centre
    • , Kui-Hin LiauAffiliated withDepartment of Surgery, Tan Tock Seng Hospital / Hepatobiliary Surgery, Medical Centre
    • , Serafin C. HilvanoAffiliated withDepartment of Surgery, Philippine General Hospital, University of the Philippines
    • , Giulio BelliAffiliated withDepartment of General and HPB Surgery, Loreto Nuovo Hospital
    • , John A. WindsorAffiliated withDepartment of Surgery, The University of Auckland
    • , Christos DervenisAffiliated withFirst Department of Surgery, Agia Olga Hospital


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.

Key words

Acute cholecystitis Diagnosis Severity of illness index Guidelines Infection