Point-of-care ultrasound in the acute abdomen and gastrointestinal emergencies: An evidence-based guide and the case for standardisation

Table 2 Tokyo Guidelines 2018 diagnostic and severity criteria relevant to bedside sonography

Item	Acute cholecystitis	Acute cholangitis
Diagnostic criteria	One local sign of inflammation + one systemic sign = suspected; + characteristic imaging = definite[21]	One item of systemic inflammation + one item of cholestasis or imaging = suspected; all three = definite[88]
Systemic inflammation	N/A	Fever > 38 °C, or laboratory evidence of an inflammatory response[88]
Cholestasis	N/A	Jaundice with total bilirubin ≥ 2 mg/dL, or liver function tests > 1.5 × upper limit of normal[88]
Imaging item	Characteristic imaging findings (wall thickening ≥ 4 mm among them)[21]	Biliary dilatation, or evidence of aetiology (stricture, stone, stent)[88]
Grade I (mild)	No organ dysfunction; mild local inflammatory change[21]	Neither grade II nor grade III criteria met[88]
Grade II (moderate)	Any one of: WBC > 18000/mm³; palpable tender RUQ mass; complaints > 72 hours; marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis)[21]	Any two of five criteria, one of which is age ≥ 75 years[88]
Grade III (severe)	Dysfunction of any one organ system: Cardiovascular (hypotension requiring dopamine ≥ 5 μg/kg per minute, or any dose of noradrenaline); neurological (decreased consciousness); respiratory (PaO2/FiO2 < 300); renal (oliguria or creatinine > 2.0 mg/dL); hepatic (PT-INR > 1.5); haematological (platelets < 100000/mm³)[21]	Organ dysfunction as for cholecystitis[88]
Management by grade	Grade I and grade II (experienced surgeons): Early laparoscopic cholecystectomy where CCI ≤ 5 and ASA-PS ≤ 2; otherwise, medical treatment and/or gallbladder drainage with interval cholecystectomy. Grade III: Early or urgent biliary drainage with delayed cholecystectomy; upfront surgery only with favourable organ-system failure, no negative predictive factors, CCI ≤ 3, ASA-PS ≤ 2, in an advanced centre[81]	Biliary drainage, urgently in severe disease[88]
Sonographic component of grading	None: Grading uses vital signs, organ-failure laboratory values, WBC, symptom duration and comorbidity indices[21]	None[88]

Criteria are reproduced from Tokyo Guidelines 2018 as cited. No element of severity grading in either condition is sonographic; ultrasound establishes the imaging item of the diagnostic criteria, after which grading is clinical and laboratory-based. ASA-PS: American Society of Anesthesiologists Physical Status; CCI: Charlson Comorbidity Index; PT-INR: Prothrombin time-international normalised ratio; RUQ: Right upper quadrant; WBC: White blood cell count; N/A: Not applicable.