Acute cholecystitis?

USTokyo TG18

Right upper quadrant pain and fever; surgery is weighing early cholecystectomy against a cholecystostomy tube.

Answer the surgeon

Early laparoscopic cholecystectomy vs percutaneous cholecystostomy in the unfit patient — gangrenous change moves it up the list.

Your answer must state:

Stones, and whether one is impacted in the neck or cystic duct
Sonographic Murphy sign
Wall thickness and gallbladder distension (TG18 lists ≥4 mm as a characteristic wall-thickness finding)
Pericholecystic fluid
Gangrenous signs: asymmetric wall, intraluminal membranes, absent Murphy in a sick gallbladder
Perforation: wall defect, pericholecystic abscess
CBD diameter — choledocholithiasis changes the operation

Key and direct findings

1.Gallstones with a positive sonographic Murphy
Maximal transducer tenderness directly over the gallbladder plus stones strongly supports the diagnosis but must be integrated with systemic inflammation and the other imaging findings.
Pitfall: Murphy is unreliable in the sedated, diabetic, or gangrenous patient — a negative Murphy does not clear a bad-looking gallbladder.
2.Wall thickening with distension
Measure the wall and gallbladder dimensions. Wall thickening and distension support acute cholecystitis in the proper clinical context but are not diagnostic alone; Tokyo Guidelines use ≥4 mm as a characteristic wall-thickness finding.
Pitfall: Wall thickening alone is nonspecific — hepatitis, heart failure, hypoalbuminemia, and ascites all thicken the wall.
3.Gangrenous signs
Asymmetric or irregular wall, intraluminal membranes or sloughed mucosa — a paradoxically silent Murphy fits gangrene, not health.
4.Perforation
A focal wall defect or pericholecystic abscess — the surgeon needs this before the first port goes in.

Supportive signs & checks

1.Pericholecystic fluid and hyperemia
Focal fluid around the gallbladder and mural hyperemia on color Doppler support the diagnosis.
2.Measure the CBD
A dilated duct raises concern for choledocholithiasis and changes preoperative or intraoperative duct-evaluation planning.
3.Acalculous cholecystitis
In the ICU patient: distension, wall thickening, and pericholecystic fluid without stones.
Pitfall: A contracted post-prandial gallbladder has a thick wall — check when the patient last ate before calling it.

Wet-read snippets

Fill the blanks, then copy into your preliminary report.

Positive

Acute calculous cholecystitis: gallstones with ___ (impacted neck stone), wall ___ mm, distended gallbladder, positive sonographic Murphy. No US signs of gangrenous change. CBD ___ mm.

Negative

Gallstones without wall thickening, distension, or sonographic Murphy — no US evidence of acute cholecystitis.

Equivocal

Cholelithiasis with borderline wall thickening (___ mm) and equivocal Murphy — indeterminate for acute cholecystitis; correlate with labs or consider CT/HIDA.

Sources

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis — Yokoe M et al. J Hepatobiliary Pancreat Sci (2018)
Meta-analysis of imaging in the diagnosis of acute cholecystitis — Kiewiet JJS et al. Radiology (2012)

Content review: Content pending clinical review · 2026-07-15

Educational reference for trained clinicians. Verify every result against the cited original guideline before use. Not a substitute for clinical judgment or medical advice.