top of page

Understanding and Managing Cholecystitis: A Comprehensive Guide for Medical Practitioners



Clinical Criteria

Local signs of inflammation

- Murphy's sign

- Right upper quadrant mass, pain, or tenderness

Systemic signs of inflammation

- Fever

- Elevated C-reactive protein (CRP)

- Elevated white blood cell count (WBC)

Imaging Findings

- Gallbladder wall thickening (>4 mm)

- Pericholecystic fluid

- Gallbladder distention

- Gallstones or sludge

- Positive sonographic Murphy's sign

Severity Grade


Grade I (Mild) Cholecystitis

- Does not meet the criteria for Grade II or Grade III

- No organ dysfunction

Grade II (Moderate) Cholecystitis

- Elevated WBC count (>18,000/mm³)

- Palpable tender mass in the right upper quadrant

- Duration of symptoms >72 hours

- Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess)

Grade III (Severe) Cholecystitis

- Cardiovascular dysfunction (hypotension requiring treatment)

- Neurological dysfunction (altered mental status)

- Respiratory dysfunction (PaO2/FiO2 ratio <300)

- Renal dysfunction (oliguria, creatinine >2.0 mg/dL)

- Hepatic dysfunction (INR >1.5)

- Hematological dysfunction (platelet count <100,000/mm³)

Severity Grade

Management Approach

Grade I (Mild)

- Conservative treatment with antibiotics and supportive care

- Elective cholecystectomy can be planned

Grade II (Moderate)

- Antibiotics and supportive care

- Early cholecystectomy (within 72 hours) is often recommended

Grade III (Severe)

- Intensive care unit (ICU) admission

- Management of organ dysfunction

- Antibiotics and supportive care

- Delayed or interval cholecystectomy after stabilization

Order Antibiotics Form





Administration Instructions



2 grams


Once daily

Administer over 30-60 minutes

Until further notice or 7 days


500 mg


Every 8 hours

Administer over 30-60 minutes

Until further notice or 7 days


Cholecystitis, a gallbladder inflammation, often presents a common clinical challenge in both emergency and outpatient settings. As a medical practitioner, it's essential to recognize the diagnostic criteria and understand the severity grading to provide optimal patient care. This blog aims to elucidate the key aspects of cholecystitis, focusing on the Tokyo Guidelines 2018, which offer a standardized approach to diagnosis and management.

Diagnostic Criteria for Cholecystitis

The Tokyo Guidelines 2018 (TG18) provide a structured framework for diagnosing cholecystitis. Diagnosis is based on a combination of clinical, systemic, and imaging findings:

1. Clinical Criteria:

  • Local signs of inflammation:

  • Murphy's sign: Pain upon palpation in the right upper quadrant during inhalation.

  • Right upper quadrant mass, pain, or tenderness.

  • Systemic signs of inflammation:

  • Fever.

  • Elevated C-reactive protein (CRP).

  • Elevated white blood cell count (WBC).

2. Imaging Findings:

  • Gallbladder wall thickening (>4 mm).

  • Pericholecystic fluid.

  • Gallbladder distention.

  • Gallstones or sludge.

  • Positive sonographic Murphy's sign.

Severity Grading of Cholecystitis

Severity grading helps tailor the management approach, ensuring patients receive appropriate care based on the risk of complications and organ dysfunction. The TG18 classifies cholecystitis into three grades:

Grade I (Mild) Cholecystitis:

  • Does not meet the criteria for severe (Grade III) or moderate (Grade II) cholecystitis.

  • No organ dysfunction and mild local inflammation.

Grade II (Moderate) Cholecystitis:

  • Presence of one or more of the following:

  • Elevated WBC count (>18,000/mm³).

  • Palpable tender mass in the right upper quadrant.

  • Duration of symptoms >72 hours.

  • Marked local inflammation (e.g., gangrenous cholecystitis, pericholecystic abscess).

Grade III (Severe) Cholecystitis:

  • Associated with organ dysfunction in any of the following systems:

  • Cardiovascular (hypotension requiring treatment).

  • Neurological (altered mental status).

  • Respiratory (PaO2/FiO2 ratio <300).

  • Renal (oliguria, creatinine >2.0 mg/dL).

  • Hepatic (INR >1.5).

  • Hematological (platelet count <100,000/mm³).

Management Based on Severity

Grade I (Mild):

  • Conservative treatment with antibiotics and supportive care.

  • Elective cholecystectomy can be planned.

Grade II (Moderate):

  • Antibiotics and supportive care.

  • Early cholecystectomy (within 72 hours) is often recommended.

Grade III (Severe):

  • Intensive care unit (ICU) admission.

  • Manage organ dysfunction.

  • Antibiotics and supportive care.

  • Delayed or interval cholecystectomy after stabilization.

Imaging Modalities in Cholecystitis

Accurate diagnosis often relies on imaging studies. The primary modalities include:

  1. Ultrasound (US): The first-line imaging modality, highly effective in detecting gallstones, wall thickening, and pericholecystic fluid.

  2. CT Scan: Useful for identifying complications such as perforation, abscess, or pancreatitis.

  3. MRI/MRCP: Provides detailed images of biliary anatomy and can identify obstructions not visible on ultrasound or CT.

Treatment Type

Management Approach

Supportive Treatment


- Ceftriaxone 1-2 g IV once daily

- Metronidazole 500 mg IV every 8 hours (in combination with ceftriaxone or ciprofloxacin for anaerobic coverage)

- Piperacillin/Tazobactam 3.375 g IV every 6 hours or 4.5 g IV every 8 hours

- Ciprofloxacin 400 mg IV every 12 hours (in combination with metronidazole)

- Levofloxacin 500-750 mg IV once daily (in combination with metronidazole)

- Ampicillin/Sulbactam 3 g IV every 6 hours

- Ertapenem 1 g IV once daily

Pain Management

- NSAIDs (e.g., ibuprofen, ketorolac)

- Opioids (e.g., morphine, hydromorphone) for severe pain


- Intravenous fluids to maintain hydration and electrolyte balance

NPO (Nil Per Os)

- Nothing by mouth to rest the gastrointestinal tract

Definitive Treatment


- Laparoscopic Cholecystectomy

- Preferred method for most patients due to shorter recovery time and fewer complications

- Open Cholecystectomy

- Indicated for patients with complicated cholecystitis or where laparoscopy is contraindicated

Percutaneous Cholecystostomy

- Alternative for critically ill patients who are not surgical candidates

- Temporary measure to drain the gallbladder and relieve symptoms

Supportive Treatment Details:

  • Antibiotics: Start empirical antibiotics based on the severity of the cholecystitis and local antibiogram, then tailor based on culture results.

  • Pain Management: Use NSAIDs for mild to moderate pain. Opioids can be used for severe pain but should be monitored for side effects.

  • Hydration: Maintain adequate hydration with IV fluids, especially in patients who are NPO.

  • NPO: Patients are typically kept NPO to rest the gastrointestinal tract and reduce gallbladder stimulation.

Definitive Treatment Details:

  • Cholecystectomy: Surgical removal of the gallbladder is the definitive treatment for cholecystitis. Laparoscopic cholecystectomy is the gold standard due to its minimally invasive nature and quicker recovery time. Open cholecystectomy is reserved for complicated cases or when laparoscopy is not feasible.

  • Percutaneous Cholecystostomy: This is a temporary measure to drain the gallbladder in critically ill patients who are not candidates for surgery. It can be a bridge to definitive surgical treatment once the patient stabilizes.

Note: Always tailor treatment plans based on individual patient conditions, comorbidities, and response to initial therapy. Multidisciplinary consultation, including surgery and infectious disease specialists, may be necessary for optimal patient management.


Recognizing the clinical and imaging criteria for cholecystitis and understanding its severity grading are pivotal in delivering effective patient care. The Tokyo Guidelines 2018 offer a comprehensive approach to diagnosing and managing this condition, ensuring patients receive timely and appropriate treatment. As healthcare providers, staying updated with such guidelines enhances our ability to manage cholecystitis efficiently, improving patient outcomes.

Stay tuned for more insights and updates on the latest guidelines and management strategies in emergency and clinical medicine. Subscribe to our blog for regular updates on critical medical topics.

Author: Uniqcret Doctor of Medicine AI

For more detailed articles and practical tips, visit our blog regularly. Let's stay informed and deliver the best patient care together!

7 views1 comment

Recent Posts

See All

1 Comment

4 days ago
  • Mild Form: Murphy’s sign is likely positive due to less muscle guarding and a palpable gallbladder.

  • Moderate/Severe Form: Murphy’s sign may be difficult to elicit due to abdominal rigidity.

Murphy's sign is a clinical test used to evaluate for cholecystitis, which is inflammation of the gallbladder. Here’s a detailed explanation and how it relates to the different forms of the disease:

Murphy's Sign


  1. The patient lies in a supine position (on their back).

  2. The examiner stands on the patient’s right side and places their hand below the right costal margin, at the midclavicular line.

  3. The patient is asked to take a deep breath.

  4. During the deep breath, the diaphragm moves downward, pushing the gallbladder down toward the examiner’s fingers.

Positive Murphy's…

Post: Blog2_Post
bottom of page