Tokyo Guidelines 2018 severity grading for acute cholecystitis
Total Score
Grade I (Mild): No organ dysfunction, no local complications. Early laparoscopic cholecystectomy within 72h is safe and recommended.
Disclaimer: The clinical scoring and algorithms on this platform are intended strictly for professional informational purposes. They do not constitute a definitive medical diagnosis, treatment, or clinical decision. The final judgment and responsibility lie with the treating physician.
Yasal Uyarı: Bu platformdaki klinik skorlamalar ve algoritmalar yalnızca sağlık profesyonellerini bilgilendirme amaçlıdır. Herhangi bir kesin tıbbi teşhis, tedavi veya klinik karar yerine geçemez. Nihai karar ve sorumluluk hastayı yatak başında değerlendiren hekime aittir.
The Tokyo Guidelines 2018 (TG18) severity grading classifies acute cholecystitis into three grades. Grade I (Mild): acute cholecystitis in a healthy patient with no organ dysfunction and mild local inflammation. Grade II (Moderate): local complications (pericholecystic abscess, gangrenous cholecystitis, perforation, emphysematous cholecystitis, hepatic abscess) or systemic markers of marked inflammation (WBC > 18,000, tender palpable mass, > 72 h duration). Grade III (Severe): organ/system dysfunction in any of six domains. Grade predicts operative difficulty and guides timing of cholecystectomy — laparoscopic cholecystectomy (LC) within 72 h is the standard for Grades I and II; Grade III requires organ support and expert surgery.
TG18 introduced the concept of 'surgical difficulty scoring' alongside severity grading. A Grade II cholecystitis in an elderly patient with dense adhesions from prior surgery may be technically more demanding than a Grade III in a young patient with a thin, well-defined gallbladder. Always combine TG18 severity grade with the TG18 surgical difficulty score and patient fitness (ASA status) when deciding on laparoscopic vs. open approach or timing.
Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. doi:10.1002/jhbp.515
Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. doi:10.1002/jhbp.516
Disclaimer: The clinical scoring and algorithms on this platform are intended strictly for professional informational purposes. They do not constitute a definitive medical diagnosis, treatment, or clinical decision. The final judgment and responsibility lie with the treating physician.
Apply TG18 grading to all patients with a confirmed or suspected diagnosis of acute cholecystitis (positive diagnostic criteria: local signs such as Murphy sign/RUQ mass, systemic signs of inflammation, and confirmatory imaging showing cholecystitis features). The grade directly determines the recommended timing and type of intervention.
TG18 recommends early laparoscopic cholecystectomy (within 72 hours of symptom onset) for both Grade I and Grade II patients when performed by a surgeon experienced in difficult cholecystectomy — a significant update from TG13, which was more conservative for Grade II. For Grade III, gallbladder drainage (PTGBD or EUS-guided) is the bridge procedure of choice before definitive surgery once the patient is stabilized.
The TG18 severity grade is based on the most severe criterion present — do not average or sum criteria across grades. A patient with WBC >18,000 (Grade II criterion) AND hypotension requiring vasopressors (Grade III criterion) is classified as Grade III, not an intermediate. Always upgrade to the highest applicable grade.