Acute Cholecystitis: Symptoms, Causes, Treatment & Emergency Signs

What is acute cholecystitis?

Acute cholecystitis is a sudden inflammation of the gallbladder, almost always caused by a gallstone blocking the cystic duct. The obstruction leads to bile stasis, increased pressure, and bacterial overgrowth. Without treatment, the gallbladder can become gangrenous, perforate, or cause life‑threatening sepsis. It is the most common serious complication of gallstones, affecting 10‑20% of patients with symptomatic gallstones. Acute cholecystitis requires prompt medical attention and often emergency or urgent cholecystectomy.

Causes – gallstones, acalculous, other

• Calculous cholecystitis (90‑95%): A gallstone impacts the cystic duct, causing obstruction. Bile accumulates, the gallbladder wall becomes inflamed, and secondary bacterial infection (E. coli, Klebsiella, Enterococcus) occurs within 24‑48 hours.
• Acalculous cholecystitis (5‑10%): Inflammation without gallstones. Occurs in critically ill patients (ICU, sepsis, burns, trauma, prolonged fasting, total parenteral nutrition). Has a higher mortality rate (20‑30%).
• Other rare causes: Tumours, parasitic infections, vasculitis, or biliary sludge.

Symptoms of acute cholecystitis – pain, fever, Murphy’s sign

Unlike biliary colic, acute cholecystitis causes persistent, severe pain that does not resolve within hours. Key features:

• Right upper quadrant (RUQ) or epigastric pain: Constant, severe, often radiating to the right shoulder or back. Lasts >6 hours (unlike biliary colic).
• Fever (typically 38‑39°C) and chills.
• Nausea and vomiting – more severe than with biliary colic.
• Tenderness in the RUQ – patient may stop breathing during deep palpation (Murphy’s sign).
• Guarding or rebound tenderness if peritonitis develops.
• Jaundice (present in 10‑20%) – suggests associated common bile duct stone or Mirizzi syndrome.

Diagnosis – blood tests, ultrasound, CT, HIDA scan

Diagnosis is based on clinical criteria (Tokyo Guidelines 2018) plus imaging:

• Blood tests: Elevated white blood cell count (WBC) – 10,000‑20,000/µL. Elevated C‑reactive protein (CRP). Mild elevation of liver enzymes (ALT, AST) and bilirubin may occur.
• Abdominal ultrasound (first‑line): Sensitivity 85‑95%. Findings:
  • Gallstones (or sludge in acalculous).
  • Gallbladder wall thickening (>4‑5mm).
  • Pericholecystic fluid (inflammatory fluid around the gallbladder).
  • Sonographic Murphy’s sign (tenderness when probe pressed over the gallbladder).
  • Distended gallbladder (>8‑10cm length).
• CT scan (if diagnosis uncertain or complications suspected): Shows wall thickening, pericholecystic fat stranding, perforation, or abscess.
• HIDA scan (hepatobiliary scintigraphy): Non‑visualisation of the gallbladder at 4 hours confirms cystic duct obstruction (sensitivity 95‑98%). Used when ultrasound is equivocal.
• MRI/MRCP: For atypical cases or suspected bile duct stones.

Treatment – antibiotics, pain relief, cholecystectomy

Treatment combines medical therapy and surgery.

• Initial management (all patients):
  • Intravenous fluids and electrolyte correction.
  • Pain relief: NSAIDs (ketorolac, diclofenac) or opioids (morphine, tramadol).
  • Antibiotics: Broad‑spectrum coverage for enteric bacteria. Regimen: piperacillin‑tazobactam, ceftriaxone + metronidazole, or ciprofloxacin + metronidazole. Duration: 3‑7 days depending on severity.
  • NPO (nothing by mouth) initially; advance to low‑fat diet as symptoms improve.
• Definitive treatment – cholecystectomy:
  • Early laparoscopic cholecystectomy (within 72 hours of symptom onset): Preferred approach. Lower conversion rate, shorter hospital stay, fewer complications than delayed surgery.
  • If patient presents after 72 hours or has severe inflammation: Some surgeons prefer interval cholecystectomy after 6‑8 weeks of antibiotic treatment. However, early surgery is still safe in many cases.
  • For critically ill patients unfit for surgery: Percutaneous cholecystostomy (drainage tube) followed by interval cholecystectomy later.

Complications of untreated acute cholecystitis

If not treated promptly, acute cholecystitis can progress to:

• Gangrenous cholecystitis (5‑10%): Necrosis of the gallbladder wall. More common in elderly, diabetics, and men. Ultrasound shows irregular wall, intraluminal membranes. Requires emergency cholecystectomy.
• Gallbladder perforation (1‑2%): Leads to peritonitis or localised abscess. High mortality (15‑25%). Emergency surgery.
• Empyema of the gallbladder: Pus‑filled gallbladder. Presents with high fever, severe toxicity. Requires urgent drainage or cholecystectomy.
• Pericholecystic abscess: Abscess around the gallbladder. Treated with percutaneous drainage and antibiotics, followed by interval cholecystectomy.
• Choledocholithiasis and cholangitis: If stones migrate into the common bile duct.

Emergency signs – when to go to the hospital

Go to the emergency department immediately if you have:

• Severe right upper quadrant or epigastric pain lasting >6 hours.
• Fever >101°F (38.5°C) with abdominal pain.
• Jaundice (yellow skin/eyes).
• Dark urine or pale stools.
• Nausea and vomiting preventing fluid intake.
• Rigid, tender abdomen (suggests perforation).
• Confusion or lethargy (possible sepsis).

Interactive FAQ – Acute cholecystitis

Disclaimer: This information is for educational purposes. If you have symptoms of acute cholecystitis, seek immediate medical attention at Vivekananda Hospital.