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Cholecystitis - acute
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Exam Tips
- Pain pattern is high yield: biliary colic is episodic, whereas acute cholecystitis is typically constant and persists for hours with systemic inflammation.
- Murphy sign supports the diagnosis but is less reliable in older adults and critically ill patients; a negative sign does not exclude disease.
- Jaundice is not typical in uncomplicated cholecystitis; if present, actively look for CBD obstruction or cholangitis.
- In OSCE/viva, state first-line imaging is RUQ ultrasound and first-line definitive treatment is early laparoscopic cholecystectomy on index admission.
- For imaging revision, review a labelled ultrasound example showing wall thickening, pericholecystic fluid, and sonographic Murphy sign in your surgical teaching atlas.
Definition
Acute cholecystitis is an acute inflammatory condition of the gallbladder, most commonly triggered by persistent obstruction of the cystic duct or gallbladder neck by a gallstone. In UK practice it typically presents as constant right upper quadrant pain with local tenderness and systemic inflammatory features, and can progress to ischaemia, necrosis, perforation, or sepsis if not treated promptly.
Pathophysiology
Around 90-95% of cases are calculous: an impacted stone causes ongoing outflow obstruction, bile stasis, rising intraluminal pressure, and chemical inflammation mediated partly by prostaglandins. Progressive distension impairs venous/lymphatic drainage and then arterial perfusion, causing mucosal ischaemia and susceptibility to secondary bacterial infection (commonly enteric Gram-negative organisms and anaerobes). Pathology may evolve from oedematous (early) to necrotizing and then suppurative disease, with risk of gangrene, perforation, and pericholecystic abscess. Acalculous cholecystitis (about 5-14%) usually occurs in critically ill patients due to gallbladder hypomotility, bile thickening, dehydration, and systemic inflammation.
Risk Factors
- Gallstones (major risk factor)
- Increasing age
- Female sex
- Obesity
- Low-fibre dietary pattern
- Critical illness (sepsis, major trauma, burns, postoperative states)
- Prolonged fasting or starvation
- Prolonged total parenteral nutrition
- Diabetes mellitus
- End-stage renal disease
- Cardiovascular disease (for example heart failure/coronary artery disease, peripheral vascular disease)
- Dehydration and fever causing bile concentration
- Drugs linked with biliary sludge (for example ciclosporin, ceftriaxone)
Clinical Features
Symptoms
- Sudden onset severe constant right upper quadrant or epigastric pain lasting hours (often longer than biliary colic)
- Pain radiating to back, right shoulder, or interscapular region
- Fever or rigors
- Nausea and vomiting
- Anorexia
- Possible jaundice (suggests biliary obstruction, Mirizzi syndrome, or CBD stone)
Signs
- Right upper quadrant tenderness +/- guarding
- Positive Murphy sign (inspiratory arrest with RUQ palpation)
- Fever, tachycardia, and other sepsis markers
- Palpable tender RUQ mass (distended gallbladder in some patients)
- Jaundice in a minority
- Peritonism or generalized abdominal tenderness if perforation/peritonitis develops
Investigations
Full blood count:Neutrophilic leukocytosis supporting acute inflammation/infection
CRP:Raised inflammatory marker; markedly high values suggest severe disease/complication
Liver blood tests (bilirubin, ALP, ALT/AST, GGT):May be normal or mildly deranged; cholestatic pattern/jaundice raises concern for CBD stone, Mirizzi syndrome, or cholangitis
Urea, electrolytes, creatinine:Assesses dehydration, renal function, and antibiotic/analgesic dosing safety
Amylase or lipase:Usually not diagnostic for cholecystitis; helps exclude or detect gallstone pancreatitis
Blood cultures (if febrile or septic):May isolate causative organisms in bacteraemia/sepsis
Right upper quadrant ultrasound (first-line imaging):Gallstones, gallbladder wall thickening, pericholecystic fluid, gallbladder distension, and sonographic Murphy sign
CT abdomen (if diagnosis uncertain or complications suspected):Can show gangrene, perforation, abscess, emphysematous change, or alternative diagnoses
MRCP or EUS (selective):Detects choledocholithiasis when biliary obstruction is suspected but ultrasound is inconclusive
Management
Lifestyle Modifications
- Urgent hospital assessment/admission; keep nil by mouth initially and give IV fluids
- Early escalation if sepsis physiology, jaundice, hypotension, or peritonism
- After recovery: weight optimisation, balanced higher-fibre diet, and counselling on recurrence risk if gallbladder remains in situ
Pharmacological Treatment
Analgesia
- Paracetamol 1 g PO/IV every 4-6 hours (maximum 4 g in 24 hours)
- Ibuprofen 400 mg PO three times daily if appropriate
- Morphine sulfate 2.5-5 mg IV titrated to response for severe pain
Avoid/limit NSAIDs in AKI, CKD, peptic ulcer disease, or high GI bleed risk; reduce opioid doses in frailty/respiratory compromise and monitor sedation.
Antiemetic
- Cyclizine 50 mg PO/IV/IM up to three times daily as required
- Ondansetron 4 mg IV/PO every 8-12 hours as required
Use QT-prolongation caution with ondansetron and review interacting medicines.
Empiric antibiotics for suspected infective cholecystitis
- Co-amoxiclav 1.2 g IV every 8 hours, then step down to 500/125 mg PO three times daily when improving
- If penicillin allergy (non-anaphylaxis local-policy dependent): cefuroxime 1.5 g IV every 8 hours plus metronidazole 500 mg IV every 8 hours
- If severe beta-lactam allergy: ciprofloxacin 400 mg IV every 12 hours plus metronidazole 500 mg IV every 8 hours
Adjust all antibiotic doses for renal function; avoid co-amoxiclav in true immediate penicillin hypersensitivity; counsel no alcohol with metronidazole; tailor to cultures and local antimicrobial policy.
Sepsis-directed supportive therapy
- IV crystalloid boluses (for example 500 mL balanced crystalloid, reassess and repeat as needed)
- Broad-spectrum IV antibiotics within 1 hour if sepsis is suspected
Follow UK sepsis pathways with urgent senior review and organ support when indicated.
Surgical / Interventional
- Early laparoscopic cholecystectomy during index admission (commonly within 72 hours to 1 week of diagnosis) is preferred definitive treatment
- Urgent surgery if gallbladder perforation, gangrene, or generalized peritonitis
- Percutaneous cholecystostomy for patients too unstable/high risk for immediate cholecystectomy
- ERCP if concurrent choledocholithiasis/cholangitis is suspected or confirmed
Complications
- Gangrenous (necrotizing) cholecystitis
- Gallbladder perforation
- Pericholecystic abscess
- Biliary peritonitis
- Empyema of the gallbladder (suppurative cholecystitis)
- Sepsis and septic shock
- Jaundice from oedema, CBD stone, or Mirizzi syndrome
- Cholecystoenteric fistula and gallstone ileus
- Recurrent attacks progressing to chronic cholecystitis
Prognosis
With prompt antibiotics, resuscitation, and early source control (usually laparoscopic cholecystectomy), outcomes are generally good. Some episodes settle conservatively, but a substantial minority develop recurrent symptoms or need surgery, and delayed or complicated disease (especially acalculous cholecystitis in critical illness) carries significantly higher mortality.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Cholecystitis - acute[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1157)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 780, 781)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 780)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1824)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 361, 362)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 49, 50)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 341)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 333)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 341)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 648, 649)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 71, 72)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 649, 650)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 116)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1316)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 115, 116)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 114)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1124)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 960)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1125)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1125)[context]