1. Elevated white cell count (> \(18000/mm^3\))
2. Renal dysfunction
3. Duration > 72 hours
4. Marked local inflammation
Select the correct answer using the code given below.
Tokyo Guidelines (TG13/TG18): Grade II (Moderate) Acute Cholecystitis
The Tokyo Guidelines grade acute cholecystitis into three severity tiers. Grade II (Moderate) is defined by the presence of any one of the following six local/systemic markers of an intense inflammatory reaction, in the absence of organ dysfunction:
- Elevated white cell count (> 18,000/mm³)
- Palpable tender mass in the right upper abdominal quadrant
- Duration of complaints > 72 hours
- Marked local inflammation — biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis
In contrast, Grade III (Severe) cholecystitis is defined by dysfunction of any one organ/system — cardiovascular (hypotension needing dopamine/noradrenaline), neurological (decreased consciousness), respiratory (PaO2/FiO2 < 300), renal (oliguria, creatinine > 2.0 mg/dL), hepatic (PT-INR > 1.5), or haematological (platelets < 100,000/mm³).
Analysis of Options
- 1. Elevated white cell count (> 18,000/mm³) — Correct; a recognised Grade II criterion.
- 2. Renal dysfunction — Incorrect for Grade II; renal dysfunction is an organ-failure criterion that defines Grade III (Severe) cholecystitis, not Grade II.
- 3. Duration > 72 hours — Correct; a recognised Grade II criterion reflecting a prolonged, established inflammatory process.
- 4. Marked local inflammation (biliary peritonitis, pericholecystic/hepatic abscess, gangrenous or emphysematous cholecystitis) — Correct; this is explicitly listed as a Grade II criterion in the Tokyo Guidelines, since it reflects severe local disease without systemic organ dysfunction.
Evaluating the Options
- Option A (1, 3 and 4) — Contains only genuine Grade II criteria. This is the correct answer.
- Option B (1, 2 and 4) — Wrongly includes renal dysfunction (a Grade III marker).
- Option C (1, 2 and 3) — Wrongly includes renal dysfunction (a Grade III marker).
- Option D (2, 3 and 4) — Wrongly includes renal dysfunction (a Grade III marker).
Conclusion
Grade II acute cholecystitis per the Tokyo Consensus Guidelines is defined by elevated WBC count, duration of symptoms > 72 hours, and marked local inflammation — not by renal dysfunction, which instead signifies organ failure and upgrades the case to Grade III (Severe). The correct answer is Option A: 1, 3 and 4.
Important Questions from Hepatobiliary & Pancreatic Surgery
Which among the following are complications of liver trauma?
1. Liver abscess
2. Biliary fistula
3. Portal thrombosis
4. Liver failure
Select the correct answer using the code given below.
Which of the following are local complications of acute pancreatitis?
1. Pseudocyst
2. Pleural effusion
3. Ileus
4. Acute fluid collection
Select the correct answer using the code given below.
Which of the following are risk factors for the development of pancreatic cancer?
1. Cigarette smoking
2. Diabetes mellitus
3. Caucasian ethnicity
4. Male gender
Select the correct answer using the code given below.
Which of the following are options for management of a pancreatic pseu- docyst?
1. Pancreaticoduodenectomy
2. Cystogastrostomy
3. Percutaneous drainage
4. Endoscopic drainage
Select the correct answer using the code given below :
- Which of the following statements regarding hepatic adenomas are correct? 1. They are almost exclusively seen in females aged 25-50 years 2. They are associated with use of oral contraceptive pills 3. They do not have any malignant potential 4. Majority are detected incidentally on imaging Select the correct answer using the code given below :
