The standard management for patients diagnosed with acute cholecystitis (AC) is antibiotics, admission and cholecystectomy. If improperly treated, significant complications can occur leading to high morbidity and mortality. Our institution implemented a pathway to discharge clinically stable patients with mild disease. This pathway included patients who were afebrile, pain-controlled, tolerating fluids, with normal white blood cell (WBC) counts, liver function tests (LFT) and lipase, with no significant comorbidities and presumed to be reliable. At discharge, they are given prescriptions and a surgical follow-up appointment. Our hypothesis is that there is a subset of reliable patients presenting to the adult ED, without significant comorbidities with mild disease, for whom emergent admission and surgery is not needed and a conservative approach is feasible. Elmhurst Hospital is a city hospital located in Queens, NY and has >100 000 visits per year. We reviewed charts of patients discharged with AC from the adult ED from March 2007 to March 2010. We excluded only incarcerated patients from analysis. Charts of all patients were examined for abnormal vitals, past medical history, WBC count, LFTs, lipase, imaging modality, administration of antibiotics and narcotics in the ED, surgical consultation, PO trial, return visits to the ED for the same complaint, surgical clinic notes and operative reports. A query of our electronic medical record revealed 574 patient charts diagnosed with AC between 3/1/07-3/10/10. Of those, 71 patients (12%) were discharged from the ED. Ages ranged from 17-78 years and 62% were female. Of those discharged, 53/71 (75%) attended surgery clinic for follow up with 34 (64%) having cholecystectomy. There were only two return visits; neither of whom experienced any significant complications or were admitted for definitive care. 16/71 (23%) did not follow up or revisit the ED. In a busy city hospital, utilization of our mild AC algorithm reduced admission rates by 12% with 75% attending their recommended follow-up appointments. Despite the 23% lost to follow-up, this review suggests that a subset of these patients can be safely discharged from the ED. This translates to significant overall cost savings and warrants further prospective study.