The incidence of gall bladder disease is high among people living in Indo-Gangetic plains [1]. Gallstones are the most common biliary pathology. It is estimated that gallstones affect 10–15% of the population in Western societies.  The prevalence of gall stones in adult population was 6.12% (men 3.07% and women 9.6%). They are asymptomatic in the majority of cases (>80%). Acute cholecystitis is the result of a blockage of the cystic duct and is called acute calculous cholecystitis when the blockage is by a stone. and a common cause for acute abdomen especially among middle-aged women and the elderly in Indian scenario. Acute cholecystitis represents 10% acute abdomen and females are commonly affected with a female to male ratio of 2:1. Although in the vast majority of cases gallbladder stones are present (calculous cholecystitis), inflammation of the gallbladder is possible in the absence of stones (acalculous cholecystitis). More than 90% of cases of AC are due to cholelithiasis, The usual symptoms among the affected patients are the pain in the right upper quadrant with fever and chills. The pain is dull aching or cramping in nature, may radiate to the back. In acute cholecystitis there is tenderness to palpation and guarding in the right upper quadrant. This process will cause arrest of inspiration with gentle pressure under the right subcostal margin, a finding known as Murphy sign. In most cases, an accurate history and physical examination, along with supporting laboratory studies and an ultrasound examination, make the diagnosis of acute cholecystitis. The Tokyo Consensus Guideline (TG13) uses the information from patient history, physical examination, blood chemistry, and ultrasound sonography. The guidelines also help in classifying AC into three grades; mild cholecystitis (grade I), moderate cholecystitis (grade II), and severe cholecystitis with organ failure (grade III) [2]. Ultrasonography in acute cholecystitis has high sensitivity and specificity. In case of gall stone disease posterior acoustic shadowing with echogenic wall of the gall bladder will be seen on USG. Gall bladder wall thickening and pericholecystic fluid collection seen in acute cholecystitis. Hepatic Iminodiacetic acid (HIDA) Scan allows evaluating physiological secretion of bile. Failure to fill the gall bladder 2 hours after injection demonstrates obstruction of cystic duct, as seen in acute cholecystitis. The generally accepted standard treatment for patients with AC who are surgically fit is Cholecystectomy, the surgical removal of the gallbladder. Currently, the minimally invasive laparoscopic technique is the prevailing procedure for the management of benign gallbladder pathologies including AC [3]. This study aims to assess the clinical spectrum and severity of acute cholecystitis, using the Tokyo Guidelines 2013 to grade pathological and biochemical findings. It also evaluates clinical, imaging, biochemical, and pathological markers, correlating them with clinical features. The objective is to improve diagnostic accuracy and guide effective patient management.

Study design- Institutional based observational cross sectional study

Study setting- Indoor patients in Dept. of General Surgery in Medical College and Hospital Kolkata

Place of study- Medical College and Hospital, Kolkata

Period of study- 18 months

Sample size- 60

Inclusion criteria-

• Patients presenting with clinical and imaging diagnosis of acute cholecystitis.

·        Patients willing to give written informed consent and to follow study procedure.

Exclusion criteria-

• Refusal to join study
• Age younger than 15 years
• Presence of any neurological/psychiatric disease
• Class 3 and 4 surgical patients as per ASA
•  Pregnancy

Statistical Analysis: Data Collection and interpretation: Data was collected and recorded using semi structured open questionnaire and proforma. Data will be analyzed with tables, charts and figures. Appropriate statistical tests was performed to correlate the different parameters and arrive at a definite conclusion.

Table 1: Distribution of Age in group and Sex

Table 2: Distribution of Visual Analog Scale

Table 3: Association between Comorbidity and Severity of AC according to Tokyo classification

Table 4: Distribution of USG Finding

Table 5: Laboratory Parameters for Liver and Renal Function Assessment

Figure 1: Distribution of Icterus

Figure 2: Distribution of mean ESR: Group

The majority of patients were aged ≤40 years (60%), with the highest representation in the ≤30 and 31–40 age groups (30% each). A statistically significant difference was observed in age distribution across the groups (P = 0.04182). Females comprised the majority of the study population (68.3%), while males accounted for 31.7%. This difference in sex distribution was statistically significant (P < 0.00001). Fever was present in 65% of the patients, while 35% did not report fever. The association was statistically significant (P = 0.0005), indicating a notable prevalence of fever among the study population. Nausea or vomiting was reported by 96.7% of the patients, with only 3.3% not experiencing these symptoms. This finding was highly significant (P < 0.00001), indicating a strong association of nausea/vomiting with the condition under study.

On the Visual Analog Scale, the majority of patients reported pain scores of 6 (38.3%), followed by scores of 7 and 8 (20.0% each). Lower scores were less frequent, with only 1.7% reporting a score of 2. The distribution was statistically significant (P < 0.00001).

Out of 60 patients, 31 (51.7%) had multiple stones with pericholecystic collection, making it the most common ultrasound finding. Other findings included single stone with pericholecystic collection in 10 patients (16.7%), and single stone with wall thickened and oedematous in 8 patients (13.3%). The distribution was statistically significant (P < 0.00001).

The mean procalcitonin levels were significantly higher in patients with more severe conditions. In mild cases, the mean was 0.3758± 0.294, in moderate cases it was 1.5706± 2.559, and in severe cases it rose to 8.1444± 3.2623. This difference was statistically significant (P < 0.0001). The mean creatinine levels increased with the severity of the condition. In mild cases, the mean creatinine was 0.7632± 0.2314, in moderate cases it was 0.9594± 0.313, and in severe cases it was 1.7556± 0.6267. This difference was statistically significant (P < 0.0001). The mean SGOT levels varied significantly across the severity groups. In mild cases, the mean SGOT was 41.8947± 10.4663, in moderate cases it was 38.5± 7.7293, and in severe cases it was 69.1222± 38.6511. This difference was statistically significant (P < 0.0001). The mean SGPT levels showed a significant increase with the severity of the condition. In mild cases, the mean SGPT was 45.5263± 15.7317, in moderate cases it was 38.2188± 9.7575, and in severe cases it was 77.2222± 24.1287. This difference was statistically significant (P < 0.0001). The mean ALP levels increased significantly with the severity of the condition. In mild cases, the mean ALP was 184.4211± 59.3907, in moderate cases it was 248.4063± 62.1506, and in severe cases it was 333.1111± 81.8908. This difference was statistically significant (P < 0.0001).The mean albumin levels decreased with the severity of the condition. In mild cases, the mean albumin was 3.3316± 0.3959, in moderate cases it was 3.2344± 0.3677, and in severe cases it was 2.7444± 0.5151. This difference was statistically significant (P= 0.002). The mean PT INR values increased with the severity of the condition. In mild cases, the mean PT INR was 1.0747± 0.1067, in moderate cases it was 1.1775± 0.177, and in severe cases it was 1.6111± 0.2902. This difference was statistically significant (P < 0.0001).

An institutional based observational cross sectional study. Department of General Surgery in Medical College and Hospital Kolkata.This period of study was January 2021- June 2022.60 patients were included in this study.

Mohandhas G et al [4] (2018) showed that acute cholecystitis (AC) one of the common surgical emergency. The highest proportion of subjects were in 46 to 50 years (28%) or 51 and above (26%) age groups.

We found that, 18 (30.0%) patients were ≤30 years of age. It was found that, the mean Age of patients was 39.7333± 11.6093. The value of z is 1.7267. The value of p is .08364. The result is not significant at p < .05.

In our study, female population 41 (68.3%) was higher than male population 19 (31.7%). male: Female ratio was 1.2.16:1. Sex was statistically significant (p< .00001) (Z=4.0166)

It was found that, higher of the patients were Hindu [34 (56.7%)] but this was statistically significant (p< .00001).

We found that, more of the patients were House wife [25 (41.7%)] but this was statistically significant (p< .00001).

Kiriyama S et al [5] (2013 Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria.

It was found that, higher of the patients had Nausea/Vomiting [58 (96.7%)] but this was statistically significant (p< .00001) .

We found that, most of the patients had Visual Analog Scale 6 [23 (38.3%)] It was statistically significant (p< .00001) .

It was found that, lower of the patients had Icterus [7 (11.7%)] but this was statistically significant (p< .00001) and in our study, all 60 (100.0%) patients had Murphys Sign.

We showed that, most of the patients had Muscle Guarding/Rigidity [42 (70%)] It was statistically significant (p< .00001) .

In our study, 1 (1.7%) patient had GB sludge, wall thickened, 4 (6.7%) patients had GB sludge, wall thickened, oedematous, 31 (51.7%) patients had multiple stone, pericholecystic collection, 6 (10.0%) patients had multiple stone, wall thickened, oedematous, 10 (16.7%) patients had single stone, pericholecystic collection and 8 (13.3%) patients had single stone, wall thickened, oedematous

We found that, most of the patients had Visual Analog Scale 6 [23 (38.3%)] It was statistically significant (p< .00001) (z=5.0208).

Charlotte S Loozen et al [6] (2016) showed that 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8–0.9), a mortality rate of 0.5 % (95 % CI 0.001–0.009) and a recurrence rate of 20 % (95 % CI 0.1–0.3).

In our study, Duration of Pain was higher in Severe [4.7778±1.3944] compared to Moderate [3.8438± .8076] and Mild [2.7895± .8550] but this was statistically significant (p<0.0001).

We found that, Visual Analog Scale was less in Mild [5.3684± 1.6737] compared to Moderate [6.2500±1.1914] and Severe [7.4444±.8819] but this was statistically significant (p=0.0011).

Our study showed that, Time Taken for Subsidence of Pain (Day) was more in Severe [8.2222± 1.8559] compared to Moderate [4.8125± 2.1013] and Mild [4.2105±1.6186] but this was statistically significant (p<0.0001).

In our study, Length of Stay in Hospital (Days) was higher in Severe [12.8889± 2.2048] compared to Moderate [7.3125± 2.4814] and Mild [2.1724± 2.4814] but this was statistically significant (p<0.0001).

Alfredo Escartín et al [7] (2021) studied 998 patients of Acute Cholecystitis of which 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC.

In my study, it was found that 31.67% mild, 53.33% moderate and 15% severe AC.

We found that, Hb was less in Mild [11.6474± 2.0462] compared to Severe [10.2000± 1.4195] and Moderate [12.2906±1.4028] but this was statistically significant (p=0.0050).

Our study showed that, TC was more in Severe [20976.7778± 3075.2501] compared to Moderate [15132.1250± 1829.0884] and Mild [13816.2105± 1848.1978] but this was statistically significant (p<0.0001).

We found that, FBS was less in Severe [248.6667± 117.9788] compared to Moderate [129.1563± 54.3959] and Severe [109.4211± 38.5102] but this was statistically significant (p<0.0001).

Our study showed that, CRP was more in Severe [110.7778± 18.0885] compared to Moderate [75.2500± 20.0274] and Mild [58.7368± 20.4419] but this was statistically significant (p<0.0001).

In our study, Procalcitonin was higher in Severe [8.1444± 3.2623] compared to Moderate [1.5706±2.5590] and Mild [.3758±.2940] but this was statistically significant (p<0.0001).

It was found that, Urea was more in Severe [63.5556±43.2207] compared to Moderate [29.0625±19.5034] and Mild [24.4737± 6.2215] and this was statistically significant (p<0.0001).

We found that, mean Creatinine (p<0.0001) which was statistically significant and Sodium (p=0.7153), Potassium (p=0.7576) this was not statistically significant.

Our study showed that, Potassium was higher in Severe [3.9111± .5840] compared to Moderate [3.8105± .3494] and Mild [3.7969± .3856] but it was not statistically significant (p=0.7576).

We found that, mean TB was higher in Severe [2.9333± 1.1281] compared to Moderate [1.3625± .2959] and Mild [1.2105±.2331] but this was statistically significant (p<0.0001).

In our study, mean DB was significantly higher in Severe [1.0778± .6996] compared to Moderate [.6063± .2514] and Mild [.5000±.1944] (p=0.0003).

We found that, SGOT was significantly higher in Severe [69.1222± 38.6511] compared to Mild [41.8947±10.4663] and Moderate [38.5000± 7.7293] (p<0.0001).

It was found that, mean SGPT was significantly higher in Severe [77.2222± 24.1287] compared to Mild [45.5263±15.7317] and Moderate [38.2188± 9.7575] (p<0.0001)

In our study, mean ALP was significantly higher in Severe [333.1111± 81.8908] compared to Moderate [248.4063± 62.1506] and Mild [184.4211±59.3907] (p<0.0001)

We found that, mean Albumin was significantly lower in Severe [2.7444±.5151] compared to Moderate [3.2344± .3677] and Mild [3.3316±.3959] (p=0.0020).

In our study, mean Amylase was higher in Mild [77.8947±36.2122] compared to Moderate [76.0000±64.0020] and Severe [74.4444± 46.8618] but it was not statistically significant (p=0.9862).

Our study showed that, mean Lipase was higher in Mild [83.4211±51.7283] compared to Moderate [82.7813±82.0703] and Severe [73.3333± 70.5691] but it was not statistically significant (p=0.9330).

In our study, mean PT INR was lower in Mild [1.0747±.1067] compared to Moderate [1.1775±.1770] and Severe [1.6111± .2902] which was statistically significant (p<0.0001).

We found that, mean PLT was significantly higher in Severe [86666.6667±10897.2474] compared to Mild [210000.0000±50990.1951] and Moderate[182093.7500±135955.4859] (p=0.0173).

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