Clinical Commander

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gi.acute-cholecystitis.core.v1

Acute Cholecystitis

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is full (TG18 + WSES 2020 + SAGES + ACDC + CHOCOLATE) with 10 phenotypes, calculator wires (NEWS2, SOFA, qSOFA, APACHE-II, CKD-EPI, BMI), and complete medication/dosing tables. Problem-package at src/lib/tier3/problem-package/packages/acute-cholecystitis/ exists with full atom set; no `_design-brief.md` for this engine. Gaps for INTEGRATED: no design brief md file; evidence.pmids array is empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files; APACHE-II calculator referenced as calc_apache2 but not in clinical-tools-registry under that id. No regimen_axes — antibiotic regimens (cefazolin, ampicillin-sulbactam, pip-tazo, ceftriaxone+metronidazole, meropenem) live in manifest.medications without RxCUI verification.

Entry points (4)

  • symptom
    Right upper quadrant pain (ACG 2024)
    ruq_pain
  • symptom
    Positive Murphy sign on exam (ACG 2024)
    murphy_sign
  • symptom
    Fever / nausea after fatty meal (ACG 2024)
    fever_after_fatty_meal
  • imaging
    US showing GB wall thickening, pericholecystic fluid (ACG 2024)
    gb_wall_thickening_us

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    TG18 thresholds, surgical risk, neoplasm risk (ACG 2024)
  • temperaturerequired
    vital • used at CONTEXT
    Fever in TG18 diagnostic criteria (ACG 2024)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia / SIRS / TG18 Grade III cardiovascular dysfunction (ACG 2024)
  • sbprequired
    vital • used at CONTEXT
    Hypotension defines TG18 Grade III; sepsis screen (ACG 2024)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    WBC >18k → TG18 Grade II (ACG 2024)
  • crprequired
    lab • used at INITIAL_WORKUP
    Severity correlation (ACG 2024)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Elevated bilirubin suggests CBD stone / Mirizzi (ACG 2024)
  • alprequired
    lab • used at INITIAL_WORKUP
    Cholestatic pattern → workup CBD stones (ACG 2024)
  • creatininerequired
    lab • used at CONTEXT
    TG18 Grade III renal dysfunction; abx dose adjustment (ACG 2024)
  • lipaserequired
    lab • used at INITIAL_WORKUP
    Exclude concurrent acute pancreatitis (ACG 2024)
  • ruq_usrequired
    imaging • used at INITIAL_WORKUP
    First-line — sonographic Murphy, wall thickening, pericholecystic fluid, distension (ACG 2024)
  • ct_abdomen
    imaging • used at BRANCHING_WORKUP
    Complications (gangrene, emphysematous, abscess, perforation) (ACG 2024)
  • mrcp
    imaging • used at BRANCHING_WORKUP
    CBD stones / Mirizzi syndrome characterization (ACG 2024)
  • pregnancy_status
    history • used at CONTEXT
    Lap chole still preferred but timing/positioning differ (ACG 2024)
  • icu_tpn_critical_illness
    history • used at CONTEXT
    Acalculous cholecystitis pathway (ACG 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm acute biliary inflammation scope; differentiate from cholangitis (CBD obstruction with infection) (ACG 2024)
    inputs: age
    advance: cholecystitis pattern matches TG18 criteria
  2. 2ENTRY
    RUQ pain + fever + Murphy or imaging suggestive of GB inflammation (ACG 2024)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, pregnancy status, ICU/TPN history, comorbidities, medications, anticoagulation (ACG 2024)
    inputs: temperature, hr, sbp, creatinine, pregnancy_status, icu_tpn_critical_illness
    advance: context captured
  4. 4RED_FLAGS
    Sepsis, peritonitis, gangrenous/emphysematous GB, perforation, Reynolds pentad (overlap with cholangitis), TG18 Grade III (ACG 2024)
    inputs: sbp, hr, temperature
    actions: calc.qsofa
    advance: shock / surgical emergency identified or excluded
  5. 5INITIAL_WORKUP
    CBC, LFT, lipase, BMP, CRP, urinalysis, beta-hCG, RUQ ultrasound (ACG 2024)
    inputs: wbc, crp, total_bilirubin, alp, lipase, ruq_us
    actions: panel.lft, panel.cbc, panel.renal
    advance: labs + US returned
  6. 6BRANCHING_WORKUP
    CT for complications (TG18 II/III); MRCP for CBD stones; HIDA if US equivocal (ACG 2024)
    inputs: ct_abdomen, mrcp
    actions: acute_abdomen
    advance: phenotype identified (calculous/acalculous, gangrenous, choledocholithiasis, Mirizzi, pregnancy)
  7. 7DIFFERENTIAL
    Distinguish from biliary colic, cholangitis, pancreatitis, hepatitis, peptic ulcer, RLL pneumonia, inferior MI (ACG 2024)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    TG18 severity grade I/II/III; ASA / APACHE-II for surgical risk; CHOCOLATE eligibility (ACG 2024)
    inputs: wbc
    actions: calc.apache2, calc.qsofa
    advance: TG18 grade + surgical risk documented
  9. 9TREATMENT
    Early lap chole (ACDC <24h) + antibiotics by grade; PTGBD bridge for unfit; ERCP for CBD stone; emergent OR for gangrenous/emphysematous (ACG 2024)
    inputs: creatinine
    advance: operative or PTGBD plan agreed
  10. 10DISPOSITION
    ICU for Grade III / emphysematous; floor for Grade I-II; OR same admission (ACG 2024)
    inputs: sbp
    advance: destination + OR slot set
  11. 11MONITORING
    Vitals q4h, daily CBC/CMP, serial abdominal exam, drain output if PTGBD, post-op diet (ACG 2024)
    inputs: wbc
    advance: clinical improvement or escalation
  12. 12FOLLOWUP
    Post-op clinic 2-4 weeks + path review; interval chole 4-6 weeks after PTGBD; LFT normalization for CBD stones (ACG 2024)
    advance: follow-up scheduled