A. Local signs of inflammation.

(1) Murphy’s sign, (2) RUQ mass/pain/tenderness

B. Systemic signs of inflammation, etc.

(1) fever, (2) elevated CRP, (3) elevated WBC count

C. Imaging findings

Imaging findings characteristic of acute cholecystitis

Suspected diagnosis: One item in A + one item in B

Definite diagnosis: One item in A + one item in B + C

Grade III (Severe) acute cholecystitis

“Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems

1. 
   

   Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≧ 5µg/kg per min, or any dose of Norepinephrine)

   
   
2. 
   

   Neurological dysfunction: decreased level of consciousness

   
   
3. 
   

   Respiratory dysfunction PaO2/FiO2 ratio < 300

   
   
4. 
   

   Renal dysfunction Oliguria, creatinine > 2.0 mg/dl

   
   
5. 
   

   Hepatic dysfunction PT-INR > 1.5

   
   
6. 
   

   Hematological dysfunction Platelet count < 100,000/mm³

Grade II (moderate) acute cholecystitis

“Grade II” acute cholecystitis is associated with any one of the following conditions.

1. 
   

   Elevated WBC count (> 18,000/mm³)

   
   
2. 
   

   Palpable tender mass in the right upper abdominal quadrant

   
   
3. 
   

   Duration of complaints > 72 hr

   
   
4. 
   

   Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade I (mild) acute cholecystitis

“Grade I” acute cholecystitis that does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure.

1. 
   

   Systemic Inflammation

   
   
   
   
   • 
     

     A-1. Fever and/or shaking chills

     
     
   • 
     

     A-2. Laboratory data: Evidence of inflammatory response

   
   
2. 
   

   Cholestasis

   
   
   
   
   • 
     

     B-1. Jaundice

     
     
   • 
     

     B-2. Laboratory data: Abnormal liver function tests

   
   
3. 
   

   Imaging

   
   
   
   
   • 
     

     C-1. Biliary dilatation

     
     
   • 
     

     C-2. Evidence of the etiology on imaging (stricture, stone, stent, etc.)

• 
  

  Suspected diagnosis: One item in A + one item in either B or C

  
  
• 
  

  Definite diagnosis: One item in A, one item in B, and one item in C

Note:

• 
  

  A-2: Abnormal white blood cell counts, increase of serum C-reactive protein levels, and other changes indicating inflammation

  
  
• 
  

  B-2: Increased serum ALP, r-GTP (GGT), AST, and ALT levels Other factors helpful in diagnosis of acute cholangitis include abdominal pain (RUQ or upper abdominal) and a history of biliary disease such as gallstones, previous biliary procedures, and placement of a biliary stent. In acute hepatitis, marked systematic inflammatory response is observed infrequently. Virological and serological tests are required when differential diagnosis is difficult.