The Yield of Fever, Inflammatory Markers and Ultrasound in the Diagnosis of Acute Cholecystitis: A Validation of the 2013 Tokyo Guidelines

Background: Each year, 1–4 % of people with known gallstones become symptomatic, either presenting with biliary colic or as acute cholecystitis. The distinction between both diagnoses remains challenging. To aid the proper diagnosis, the revised 2013 Tokyo Guidelines (TG 2013) were proposed with a self-acclaimed diagnostic accuracy of over 90 %. However, this accuracy has not been verified by others so far. Objective: To determine the accuracy of the TG 2013 guidelines in the diagnosis of acute cholecystitis both in its single components of fever, inflammatory markers and US features and of the combined application of the TG 2013 guidelines as a whole. Methods: A 5-year retrospective analysis equal to the TG 2013 validation process of all emergency cholecystectomies for acute cholecystitis or persistent biliary pain with an ultrasound performed during the same admission. Acute cholecystitis at histology was the golden standard. Results: Inclusion criteria were met by 169 patients with a prevalence of acute cholecystitis of 52.7 %. The individual features of fever, gallbladder wall thickening and probe tenderness were not significant in univariate analysis. In multivariate analysis only, neutrophil count was an independent predictor. The combined application of the TG 2013 guidelines led to a better sensitivity of 83.1 % at the cost a reduced specificity of 37.5 % compared to neutrophil count alone. The accuracy was therefore only 60.3 %, which was well below the TG 2013 report. Conclusion: The 2013 Tokyo Guidelines were slightly better in predicting acute cholecystitis but over diagnosed two-thirds of normal gallbladders compared to neutrophil count alone.