Table 1. Data Dictionaries for Grading System for EGS Conditions A. Acute Appendicitis I Description Acutely inflamed appendix, intact Gangrenous appendix, intact Perforated appendix with local contamination Perforated appendix with periappendiceal phlegmon or Perforated appendix with generalized Clinical Criteria Pain, leukocytosis and right lower quadrant (RLQ) tenderness Pain, leukocytosis and RLQ tenderness Pain, leukocytosis and RLQ tenderness Pain, leukocytosis and RLQ tenderness; may have palpable mass (CT findings) Inflammatory changes localized to appendix +/- appendiceal dilation +/- contrast non-filling Appendiceal wall necrosis with contrast nonenhancement +/- air in appendiceal wall Above with local periappendiceal fluid +/- contrast extravasation Regional soft tissue inflammatory changes, phlegmon or Generalized Diffuse abdominal or pelvic inflammatory changes +/- free intraperitoneal fluid or air Acutely inflamed appendix, intact Gangrenous appendix, intact Above, with evidence of local contamination Above, with or phlegmon in region of appendix Above, with addition of generalized purulent contamination away from appendix Presence of neutrophils at the base of crypts, submucosa +/- in muscular wall Mucosa and muscular wall digestion; not identifiable on hematoxylin and eosin stain (H & E) Gross or focal dissolution of muscular wall Gross Gross 1 P a g e
B. Breast Infections Description Clinical Criteria (US or CT findings) I Breast cellulitis Erythema, induration, edema, pain, tenderness Simple Single, small without loculations; not involving the nipple/areolar complex Complex Large with multiple loculations, multiple es, or involving nipple/areola complex; lymphadenopathy Breast with axillary extension Breast with ipsilateral lymphadenopathy, thrombophlebitis, lymphangitis Inflammation without fluid collection Single well circumscribed fluid collection within breast tissue, not involving nipple/areolar complex Multiple separate fluid collections or single large collection with multiple loculations within breast tissue or involvement of nipple/areola complex Fascial plane thickening with enhancement; evidence of lymphadenopathy on US or CT Operative Criteria Single, well circumscribed fluid collection within breast tissue, not involving nipple/ areola complex Multiple separate fluid collections or single large collection with multiple loculations within breast tissue, or involvement of nipple/areola complex; enlarged lymph nodes Above, plus axillary fluid collections, extension of inflammatory changes well beyond the es Pathologic Criteria limited to breast tissue limited to breast tissue with cultures positive for organism if available of breast tissue and axillary lymph nodes with cultures positive for 2 P a g e
Breast with chest wall involvement Above, plus erosion into chest wall muscles or ribs or pleural space, or necrotizing fasciitis Above, plus inflammatory changes in the chest wall muscles, ribs or pleural space Above, with erosion into chest wall muscles or ribs or pleural space, or necrotizing fasciitis involving chest wall, fascia, muscles or ribs with or without necrosis and cultures positive for 3 P a g e
C. Acute Cholecystitis Description Clinical Criteria (CT/US/HIDA findings) I Acute cholecystitis GB empyema or gangrenous cholecystitis or emphysematous cholecystitis GB with local contamination GB with pericholecystic or gastrointestinal fistula Right upper quadrant (RUQ) or epigastric pain; Murphy s Sign; leukocytosis RUQ or epigastric pain; Murphy s Sign; leukocytosis Localized in RUQ Localized at multiple locations; abdominal distention with symptoms of bowel obstruction Wall thickening; distention; gallstones or sludge; pericholecystic fluid; non-visualization of gallbladder (GB) on hepatobiliary iminodiacetic acid (HIDA) scan Above, plus air in GB lumen, wall or in the biliary tree; focal mucosal defects without frank HIDA with focal transmural defect, extraluminal fluid collection or radiotracer but limited to RUQ Abscess in RUQ outside GB; bilio-enteric fistula; gallstone ileus Inflammatory changes localized to GB; wall thickening; distention; gallstones Distended GB with pus or hydrops; necrosis or gangrene of wall; not perforated Perforated GB wall (non-iatrogenic) with bile outside the GB but limited to RUQ Pericholecystic ; bilio-enteric fistula; gallstone ileus Acute inflammatory changes in the GB wall without necrosis or pus Above, plus pus in the GB lumen; necrosis of GB wall; intramural ; epithelial sloughing; no Necrosis with of the GB wall (non-iatrogenic) Necrosis with of the GB wall (non-iatrogenic) GB with generalized Above, with generalized Free intra-peritoneal bile Above, plus generalized Necrosis with of the GB wall (non-iatrogenic) 4 P a g e
D. Acute Diverticulitis of the Colon I Description Clinical Criteria (CT findings) Colonic Pain; leukocytosis; Mesenteric stranding; inflammation minimal or no colon wall thickening tenderness Colon micro or pericolic phlegmon without Localized pericolic Distant and/or multiple es Free colonic with generalized Local tenderness (single or multiple areas) without Pericolic phlegmon; foci of air (single or multiple); no Operative Criteria Pericolic phlegmon with no Pathologic Criteria Inflamed colon with microscopic Localized Pericolic Pericolic Inflamed colon with Localized at multiple locations Abscess or phlegmon away from the colon Generalized Free air and free fluid Abscess or phlegmon away from the colon generalized fecal and purulent contamination Inflamed colon with Inflamed colon with 5 P a g e
E. Esophageal Perforation Operative Criteria Pathologic criteria Description Clinical Criteria Imaging and/or endoscopic criteria I Mucosal tear Dysphagia; chest pain, upper abdominal pain or back pain; breathing problems No abnormality or possible intramural air Preservation of normal anatomy with dissection required to identify inflammation Partial thickness or mucosal tear Full thickness tear with minimal inflammation Full thickness tear with localized Esophageal wall necrosis Empyema; ; mediastinitis Above, with subcutaneous emphysema Above, with vomiting and ill-appearing Esophageal thickening Obvious inflammation Full thickness with minimal inflammation without mediastinitis or Air in prevertebral planes Presence of inflammation and stigmata of with contained collection As above Mediastinal widening Inflammation; necrosis of the esophageal wall with localized contamination As above Pleural effusion disseminated contamination; erosion into adjacent structures (chest, mediastinum, or abdomen) Mediastinal inflammation or emphysema Severe mediastinal necrosis Pleural invasion or empyema 6 P a g e
F. Hernias (Internal or Abdominal wall) Description Clinical Criteria I Reducible hernia Palpable, reducible hernia without fever or leukocytosis Incarcerated hernia without bowel ischemia Incarcerated with bowel ischemic but viable Incarcerated hernia with gangrenous bowel or with local spillage Incarcerated with and diffuse peritoneal contamination Local tenderness with non-reducible palpable hernia. No fever of leukocytosis. Local tenderness with non-reducible palpable hernia; may be associated with fever, tachycardia, or leukocytosis Local tenderness with guarding, non-reducible palpable hernia with associated skin changes such as erythema Diffuse abdominal tenderness with guarding or rebound; non-reducible palpable hernia with associated skin changes such as erythema (CT findings) Hernia visible on CT Hernia visible on CT Hernia visible on CT with local stranding or inflammatory changes Hernia visible on CT with local stranding or inflammatory changes as well as contained fluid collection Hernia visible on CT with local stranding or inflammatory changes as well as diffuse fluid collections and inflammation Abdominal wall defect present Abdominal wall defect present with abdominal contents lodged in defect; healthy appearing viscera Abdominal wall defect present with abdominal contents lodged in defect; visibly inflamed but viable appearing viscera Abdominal wall defect present with abdominal contents lodged in defect; gangrenous or perforated abdominal contents Abdominal wall defect present with abdominal contents lodged in defect; gangrenous or perforated abdominal contents with diffuse contamination Local necrosis or Local necrosis or 7 P a g e
G. Infectious Colitis Description Clinical Criteria ( CT findings) I Mucosal disease with positive cultures or other confirmatory laboratory testing Diarrhea and/or abdominal pain with positive stool cultures or toxin assays; inflamed mucosa on endoscopy Normal CT Normal colon Mucosal inflammatory changes on biopsy, positive stool cultures or toxin assays Colon wall thickening by cross-sectional imaging or pseudomembranes on endoscopy Colon wall thickening with ascites or diffuse colonic dilation or diffuse coalescing pseudomembranes Diarrhea and/or abdominal pain, and/or abdominal tenderness with pseudomembranes on endoscopy Abdominal pain and tenderness and/or distension; coalescing pseudomembranes by endoscopy Localized colonic wall thickening Diffuse colonic thickening or localized thickening and free intraabdominal fluid Localized thickened but otherwise normal colon Diffusely thickened colon or localized thickening with free intra-abdominal fluid Transmural colonic inflammation Transmural colonic inflammation 8 P a g e
Description Clinical Criteria Localized colonic necrosis, with or without Diffuse transmural colonic necrosis, with or without Abdominal pain with and mucosal necrosis by endoscopy Abdominal pain with mucosal necrosis by endoscopy ( CT findings) Colonic thickening with free fluid +/- evidence of or Colonic thickening with free fluid +/- evidence of or Colonic thickening with localized or discontinuous transmural necrosis or ischemia with or without or Diffuse colonic necrosis with or without or Transmural colonic inflammation with areas of necrosis Transmural colonic inflammation with areas of full thickness necrosis 9 P a g e
H. Intestinal Obstruction Due to Adhesions Description Clinical Criteria (CT findings) I Partial SBO Some flatus; normal or Normal imaging or hypoactive bowel minimal intestinal sounds; minor distension abdominal distention Complete SBO; bowel viable and not compromised Complete SBO with compromised but viable bowel Complete SBO with non-viable bowel or with localized spillage SB with diffuse peritoneal contamination Minimal to no flatus; hypoactive bowel sounds; distension without generalized tenderness No flatus; absent bowel sounds; abdominal distension with localized tenderness Obstipation; abdominal distension with diffuse tenderness, rebound, guarding Abdominal distension with evidence of Intestinal distension with transition point; delayed contrast flow with some distal contrast; no evidence of bowel compromise Intestinal distension with transition point and no distal contrast flow; evidence of complete obstruction or impending bowel compromise Evidence of localized or free air; bowel distension with free air or free fluid Bowel with free air and free fluid Operative Criteria Minimal intestinal distension with no evidence of bowel obstruction Intestinal distention with transition point; no evidence of bowel compromise Intestinal distention with impending bowel compromise Intestinal distension with localized or free fluid Intestinal distension with, free fluid and evidence of diffuse Pathologic criteria Bowel gangrene or Bowel gangrene or 10 P a g e
I. Intestinal Arterial Ischemia of the Bowel Description Clinical Criteria (CT findings) I Bowel ischemia without tissue loss Bowel ischemia with mucosal ulceration only, without transmural infarction Segmental transmural bowel infarction without Segmental transmural bowel infarction with Anorexia with abdominal pain Abdominal pain out of proportion to exam; no Abdominal pain and tenderness without Abdominal pain and tenderness with Wall thickening and mucosal edema with enhancement. Wall thickening and edema without enhancement; mesenteric vessel occlusion Wall thickening without mucosal or intestinal wall enhancement; intramural, portal, or mesenteric pneumatosis Pneumoperitoneum, contrast extravasation, Normal appearing bowel Normal serosa, mucosal ischemia and ulceration Transmural necrosis without Transmural necrosis with and Ischemia without ulceration Mucosal ulceration Transmural necrosis without Transmural necrosis with Pan-intestinal infarction Abdominal pain and tenderness with or above with involvement of both Superior Mesenteric Artery and Inferior Mesenteric Artery distributions Pan-intestinal infarction and necrosis with or without Transmural infarction with 11 P a g e
J. Acute Pancreatitis Description Clinical Criteria (CT findings) I Acute edematous pancreatitis Midepigastric abdominal pain and tenderness; elevated amylase and/or lipase Pancreatitis without phlegmon, necrosis, peripancreatic fluid collection or Edematous pancreas Pancreatic phlegmon or peripancreatic fluid collection or hemorrhage Sterile pancreatic necrosis Midepigastric abdominal pain and tenderness; elevated amylase and/or lipase Midepigastric abdominal pain and tenderness; elevated amylase and/or lipase Phlegmon or peripancreatic fluid collection or hemorrhage Pancreatic necrosis without extraluminal air or Pancreatic phlegmon or peripancreatic fluid collection Pancreatic necrosis without purulence or Gram stain and culture of necrosis negative for Infected pancreatic necrosis or Severe midepigastric abdominal pain and tenderness; elevated amylase and/or lipase Pancreatic necrosis with extraluminal air or Pancreatic necrosis with purulence or Gram stain and culture of necrosis or positive for Extra-pancreatic extension of pancreatic necrosis involving adjacent organs, such as colonic necrosis Severe diffuse midepigastric abdominal pain and tenderness; elevated amylase and/or lipase Extra-pancreatic extension of necrosis involving adjacent organs, such as colonic necrosis Involvement or necrosis of adjacent organs Involvement or necrosis of resected adjacent organs 12 P a g e
K. Pelvic Inflammatory Disease I Description Inflammation of the cervix Purulent cervical drainage Inflammation of the tubes, ovaries, and/or entire uterus Tubo-ovarian, pyometra Clinical Criteria (CT or US findings) None None OR vaginal discharge, vaginal irritation, pelvic discomfort Above, plus pelvic pain or discomfort; fever Severe pelvic pain; fever None or positive cervical cultures for Inflammation of pelvic organ or organs Inflammation and of pelvic organ or organs None, or purulent pelvic fluid on laparoscopy Drainage of tuboovarian or pyometra None or positive cervical cultures for None, or positive cervical or pelvic cultures for Generalized pelvic sepsis Generalized Single or multiple es, widespread inflammation Drainage of fluid collections, complications related to es, such as interloop es causing bowel obstruction; hysterectomy None, or positive cervical or pelvic cultures for 13 P a g e
L. Perforated Peptic Ulcer Disease (Gastric or Duodenal) Description Clinical Criteria (CT findings) I Micro without Contained with localized localized and localized fluid collection in lesser sac or RUQ Free with duodenal destruction ± penetration into adjacent organs and generalized Discomfort in the epigastric region Tenderness confined to the right upper quadrant (RUQ) Tenderness confined to the RUQ Diffuse Diffuse Extraluminal gas with no associated inflammatory changes Extraluminal gas contained in a walled off collection or the retroperitoneum associated collection that is not contained in a anatomic space or but not disseminated disseminated air and fluid disseminated air and fluid with loss of local anatomic planes at the site of Preservation of normal anatomy with dissection required to identify the Presence of inflammation and stigmata of with contained collection Inflammation and contamination of peritoneal cavity confined to the RUQ disseminated succus or purulent disseminated succus or purulent and erosion into adjacent structures minimal bowel wall inflammation bowel wall inflammation bowel wall inflammation bowel wall inflammation Destructive erosion of involved structures 14 P a g e
M. Perirectal Abscess Description Clinical Criteria I Perianal Anal pain and swelling, erythema, tenderness Drainage of localized pus Intersphincteric or ischiorectal Horseshoe Supralevator Necrotizing soft tissue infection of the perineum, buttocks, etc., AKA Fournier s gangrene Fever; perineal pain; diffuse swelling; pain with defecation; palpable fluctuant area on digital examination Pain with defecation; palpable fluctuant area on digital examination Fever; may present with sepsis or perineal discomfort; may have no localized clinical signs Systemic signs of sepsis, perineal pain and swelling, cellulitis, crepitus, necrotic skin changes Endorectal ultrasound localization; CT may localize collection but MRI preferable Endorectal ultrasound localization; CT may localize collection but MRI preferable Endorectal ultrasound not useful; CT demonstrating collection X-ray or CT may demonstrate air in soft tissues. CT or MRI may demonstrate intraabdominal or retroperitoneal source of infection. Drainage of localized pus Drainage of localized pus Drainage of localized pus Necrotic skin and soft tissue of perianal, perineal, and genitalia Culture of positive for Culture of positive for Culture of positive for Above, plus necrotic skin and soft tissue of perianal, perineal, and genitalia 15 P a g e
N. Pleural Space Infection Description Clinical Criteria I Retained hemothorax or pleural effusion with positive pleural fluid cultures Leukocytosis, fever, chest pain Pleural fluid consistent with blood or infected fluid no evidence of loculations Retained blood, blood clot, or other nonpurulent fluid without lung trapping. Culture of fluid positive for Purulent, freeflowing pleural effusion or hemothorax by imaging Fibrinopurulent stage with loculated areas of effusion or hemothorax Organizing stage with evidence for restricted lung expansion and pulmonary mechanics Respiratory failure, leukocytosis, fever, chest pain Respiratory failure, leukocytosis, fever, chest pain Severe respiratory failure, leukocytosis, fever, chest pain Pleural fluid consistent with blood or infected fluid; no evidence of loculation Pleural fluid consistent with blood or infected fluid, with evidence of loculation Pleural fluid consistent with blood or infected fluid with evidence of loculation; significantly decreased lung volumes Retained blood, blood clot, with purulent areas OR completely purulent fluid. Retained blood, blood clot or other purulent fluid with limited lung trapping Retained blood, blood clot or other purulent fluid with diffuse pleural inflammation and lung trapping Culture of fluid positive for Culture of fluid positive for with areas of fibrous peel Culture of fluid positive for with areas of fibrous peel Spontaneous external drainage or spreading extra-thoracic Severe respiratory failure, leukocytosis, fever, chest pain Above, plus severe inflammatory changes of adjacent abdominal, Above, with external drainage or necrotizing soft tissue infection of mediastinum, Above, with necrotic soft tissue from mediastinum, or subcutaneous space 16 P a g e
necrotizing soft tissue infection mediastinal or subcutaneous tissue diaphragm or subcutaneous tissues 17 P a g e
O. Soft Tissue Infections Description Clinical Criteria I Cellulitis Folliculitis, erysipelas, impetigo, simple cellulitis Superficial necrosis or liquefaction Subcutaneous Abscess Necrotizing, blistering or bullous cellulitis or skin necrosis Subcutaneous (CT findings) Superficial inflammation with no subcutaneous stranding Subcutaneous stranding, but no Well defined (walled off) subcutaneous fluid collection with surrounding inflammation Fasciitis Fasciitis Inflammation extending to fascia; likely air along fascia margins Myonecrosis Myonecrosis Air deep to fascia; likely poor perfusion of muscle Well defined subcutaneous fluid collection Clear involvement of fascia with healthy, viable muscle underneath. Extension of necrosis into muscle and deeper tissue involving epidermis only involving epidermis and dermis involving epidermis, dermis, and subcutaneous fat with cultures positive for if available involving epidermis, dermis, sub-cutaneous fat, and muscular fascia with cultures positive for if available involving epidermis, dermis, sub- cutaneous fat, muscular fascia, adjacent tissue (muscle, etc.) with cultures positive for if available 18 P a g e
P. Surgical Site Infections Description Clinical Criteria I Infection involving skin only Infection involving subcutaneous tissue Infection involving fascia or muscle layer Infection involving body cavity or deep space that was opened or manipulated One or more of the following: periincisional erythema, warmth, pain, swelling without induration, exudate, or wound separation One or more of the following: periincisional erythema warmth, pain, swelling plus induration or exudate confined to subcutaneous tissues Subcutaneous or phlegmon extending to muscle or fascia Above, plus separation of fascia or subfascial (CT findings) Soft tissue inflammatory changes, phlegmon or in subcutaneous tissues Regional soft tissue inflammatory changes, phlegmon or involving muscle or fascia Phlegmon or extending deep to muscle or fascia OR fascial dehiscence at surgical site Phlegmon or in subcutaneous tissues Phlegmon or involving muscle or fascia Phlegm on or extending deep to muscle or fascia OR facial wound dehiscence limited to subcutaneous tissues involving muscle or fascia with cultures positive for organism if available involving fascia and underlying tissues with cultures positive 19 P a g e
during the surgery for organism if available Infection involving body cavity or deep space away from the site that was opened or manipulated during surgery Purulent drainage in a body cavity away from the operative site Phlegmon or in body cavity or deep space extending deeper than the fascia/deep muscle incision Phlegmon or in body cavity or deep space extending deeper than the fascial/deep muscle incision in body cavity or deep space away extending deeper than the fascial/deep muscle incision with cultures positive for if available 20 P a g e