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gi.acute-cholecystitis.core.v1PRODUCTION
gi.acute-cholecystitis.core.v1

Acute Cholecystitis

gastroenterologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute biliary inflammation scope; differentiate from cholangitis (CBD obstruction with infection) (ACG 2024)

Inputs
1
Actions
0
Advance rule
Set
Advance when

cholecystitis pattern matches TG18 criteria

Patient inputs (15)

TG18 thresholds, surgical risk, neoplasm risk (ACG 2024)

Fever in TG18 diagnostic criteria (ACG 2024)

Tachycardia / SIRS / TG18 Grade III cardiovascular dysfunction (ACG 2024)

Hypotension defines TG18 Grade III; sepsis screen (ACG 2024)

TG18 Grade III renal dysfunction; abx dose adjustment (ACG 2024)

WBC >18k → TG18 Grade II (ACG 2024)

Severity correlation (ACG 2024)

Elevated bilirubin suggests CBD stone / Mirizzi (ACG 2024)

Cholestatic pattern → workup CBD stones (ACG 2024)

Exclude concurrent acute pancreatitis (ACG 2024)

First-line — sonographic Murphy, wall thickening, pericholecystic fluid, distension (ACG 2024)

Complications (gangrene, emphysematous, abscess, perforation) (ACG 2024)

CBD stones / Mirizzi syndrome characterization (ACG 2024)

Lap chole still preferred but timing/positioning differ (ACG 2024)

Acalculous cholecystitis pathway (ACG 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningtg18_grade_iii_organ_failure
    TG18 grade III — organ dysfunction (CV, neuro, resp, renal, hepatic, hematologic) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggangrenous_or_emphysematous_cholecystitis
    CT shows gangrene, gas in GB wall (emphysematous), or wall hemorrhage (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningperforation_peritonitis
    Free intraperitoneal fluid + air, peritoneal signs (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconcurrent_choledocholithiasis_or_cholangitis
    Bilirubin >4 + CBD dilation + Charcot triad — cholangitis overlap (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunfit_for_surgery_TG18_II_III
    TG18 II-III in surgical-prohibitive patient (severe comorbidity, ASA IV-V) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacalculous_cholecystitis_critical_illness
    ICU/TPN/major surgery patient with new RUQ inflammation, gallbladder distension without stones (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute cholecystitis — TG18 grade-driven antibiotics + early lap cholecystectomy (ACDC) (ACG 2024)
axis: cholecystitis_TG18_pathwaystep 1 - Step 1 — TG18 Grade I (mild) — community-acquired
Selected step "Step 1 — TG18 Grade I (mild) — community-acquired" — No organ dysfunction, no severe local inflammation, healthy host
  • cefazolin
    first line
    cephalosporin_1st_gen
    1-2 g IV q8h • IV • q8h
    triggers: mild_TG18_grade_I_community_acquired
    TG18 — narrow-spectrum gram-positive + most enteric gram-negatives; appropriate for grade I CAI (ACG 2024)
    rxcui 2180
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV daily • IV • daily
    triggers: mild_TG18_grade_I_with_LFT_abnormalities
    Broader gram-negative coverage when biliary stasis suspected (ACG 2024)
    rxcui 2193

ed playbook — drug actions (6)

  1. 1. crystalloid
    1-2 L IV bolus or 30 mL/kg if septic • IV • PRN
    trigger: Hypovolemia/sepsis (ACG 2024)
    Resuscitation (ACG 2024)
  2. 2. cefazolin (grade I)
    1-2 g IV q8h • IV • q8h
    trigger: TG18 grade I community-acquired (ACG 2024)
    Narrow-spectrum first-line (ACG 2024)
  3. 3. pip-tazo (grade II)
    4.5 g IV q6h • IV • q6h
    trigger: TG18 grade II OR healthcare-associated (ACG 2024)
    Broad-spectrum (ACG 2024)
  4. 4. meropenem (grade III)
    1 g IV q8h • IV • q8h
    trigger: TG18 grade III severe sepsis (ACG 2024)
    Severe sepsis coverage (ACG 2024)
  5. 5. hydromorphone
    0.5-1 mg IV q3-4h PRN • IV • PRN
    trigger: Pain (ACG 2024)
    Multimodal (ACG 2024)
  6. 6. ondansetron
    4 mg IV q6h PRN • IV • PRN
    trigger: Nausea (ACG 2024)
    Symptom control (ACG 2024)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Right upper quadrant pain (ACG 2024); Positive Murphy sign on exam (ACG 2024); Fever / nausea after fatty meal (ACG 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Cholecystitis** (gi.acute-cholecystitis.core.v1).
Phenotype framing: Distinguish from biliary colic, cholangitis, pancreatitis, hepatitis, peptic ulcer, RLL pneumonia, inferior MI (ACG 2024)
Scope: Confirm acute biliary inflammation scope; differentiate from cholangitis (CBD obstruction with infection) (ACG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute cholecystitis — TG18 grade-driven antibiotics + early lap cholecystectomy (ACDC) (ACG 2024)** — step "Step 1 — TG18 Grade I (mild) — community-acquired".
1. cefazolin 1-2 g IV q8h IV q8h (cephalosporin_1st_gen, first line) — TG18 — narrow-spectrum gram-positive + most enteric gram-negatives; appropriate for grade I CAI (ACG 2024)
2. ceftriaxone 2 g IV daily IV daily (cephalosporin_3rd_gen, first line) — Broader gram-negative coverage when biliary stasis suspected (ACG 2024)

Setting playbook (ed) — Diagnose acute cholecystitis (TG18 criteria), risk-stratify (TG18 grade), start empiric antibiotics, surgical consult for early lap chole (ACDC <72h) (ACG 2024)
3. crystalloid 1-2 L IV bolus or 30 mL/kg if septic IV PRN — Hypovolemia/sepsis (ACG 2024) (Resuscitation (ACG 2024))
4. cefazolin (grade I) 1-2 g IV q8h IV q8h — TG18 grade I community-acquired (ACG 2024) (Narrow-spectrum first-line (ACG 2024))
5. pip-tazo (grade II) 4.5 g IV q6h IV q6h — TG18 grade II OR healthcare-associated (ACG 2024) (Broad-spectrum (ACG 2024))
6. meropenem (grade III) 1 g IV q8h IV q8h — TG18 grade III severe sepsis (ACG 2024) (Severe sepsis coverage (ACG 2024))
7. hydromorphone 0.5-1 mg IV q3-4h PRN IV PRN — Pain (ACG 2024) (Multimodal (ACG 2024))
8. ondansetron 4 mg IV q6h PRN IV PRN — Nausea (ACG 2024) (Symptom control (ACG 2024))

Non-pharmacologic actions:
- NPO (ACG 2024)
- IV access (ACG 2024)
- Surgical consult on admission for early lap cholecystectomy (within 72h per ACDC) (ACG 2024)
- IR consult if PTGBD bridge needed (TG18 grade III in surgical-prohibitive) (ACG 2024)
- ERCP if concurrent CBD stone (raised bilirubin + CBD dilation) (ACG 2024)

AVOID / contraindication checks:
- NPO_until_post_op (ACG 2024)
- De_escalate_antibiotics_per_culture (ACG 2024)
- Carbapenem_reserved_for_grade_III_or_ESBL (ACG 2024)
- NSAID_avoid_in_septic_AKI (ACG 2024)

Monitoring

Regimen monitoring:
- serial WBC CRP (ACG 2024)
- LFT trend (ACG 2024)
- temperature q4h (ACG 2024)
- lactate in severe
- response to antibiotics within 24 48h (ACG 2024)
- duration 24h post op for uncomplicated (ACG 2024)
- duration 4 to 7 days for complicated (ACG 2024)

Setting (ed) monitoring:
- Vitals q4h (ACG 2024)
- Daily WBC, CRP, LFTs (ACG 2024)
- SpO2 (ACG 2024)
- Lactate if severe (ACG 2024)

Follow-up plan: Post-op clinic 2-4 weeks + path review; interval chole 4-6 weeks after PTGBD; LFT normalization for CBD stones (ACG 2024)
- Close-out criterion: follow-up scheduled

Monitoring phase: Vitals q4h, daily CBC/CMP, serial abdominal exam, drain output if PTGBD, post-op diet (ACG 2024)

Disposition

Current setting: ed — Diagnose acute cholecystitis (TG18 criteria), risk-stratify (TG18 grade), start empiric antibiotics, surgical consult for early lap chole (ACDC <72h) (ACG 2024)

Disposition criteria:
- Discharge home (rare): mild biliary colic without true cholecystitis, surgical follow-up (ACG 2024)
- Admit ward: TG18 grade I-II for early lap chole within 72h (ACG 2024)
- Admit ICU: TG18 grade III, septic shock (ACG 2024)
- OR: emergent for gangrenous/perforation/peritonitis (ACG 2024)

Escalation triggers (move to higher acuity):
- TG18 grade III organ failure → ICU + emergent surgery vs PTGBD (ACG 2024)
- Gangrenous/emphysematous cholecystitis → emergent OR (ACG 2024)
- Perforation with peritonitis → emergent OR (ACG 2024)
- Mirizzi or large CBD stones → ERCP first (ACG 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] TG18 grade III — organ dysfunction (CV, neuro, resp, renal, hepatic, hematologic) (ACG 2024)
- [LIFE_THREATENING] CT shows gangrene, gas in GB wall (emphysematous), or wall hemorrhage (ACG 2024)
- [LIFE_THREATENING] Free intraperitoneal fluid + air, peritoneal signs (ACG 2024)

Citations

- Tokyo Guidelines 2018 (TG18) + WSES 2020 Acute Calculous Cholecystitis + SAGES Safe Cholecystectomy 2020 + ACDC Trial (Ann Surg 2013) + CHOCOLATE Trial (BMJ 2018) [PMID:29032636](https://pubmed.ncbi.nlm.nih.gov/29032636/)
- Cited evidence (PMID 29090866) [PMID:29090866](https://pubmed.ncbi.nlm.nih.gov/29090866/)
- Cited evidence (PMID 24022431) [PMID:24022431](https://pubmed.ncbi.nlm.nih.gov/24022431/)
- Cited evidence (PMID 30297544) [PMID:30297544](https://pubmed.ncbi.nlm.nih.gov/30297544/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Tokyo Guidelines 2018 (TG18) + WSES 2020 Acute Calculous Cholecystitis + SAGES Safe Cholecystectomy 2020 + ACDC Trial (Ann Surg 2013) + CHOCOLATE Trial (BMJ 2018) — PMID:29032636
  • Cited evidence (PMID 29090866) — PMID:29090866
  • Cited evidence (PMID 24022431) — PMID:24022431
  • Cited evidence (PMID 30297544) — PMID:30297544