Acute Cholecystitis

1. Clinical Overview

Definition and Importance

Acute cholecystitis is an acute inflammatory condition of the gallbladder, most commonly resulting from cystic duct obstruction by an impacted gallstone. This condition represents one of the most frequent indications for emergency abdominal surgery worldwide, with approximately 20% of patients with symptomatic gallstones developing acute cholecystitis during their lifetime.[1] The Tokyo Guidelines (TG18/TG21) provide internationally validated diagnostic criteria and severity grading that have standardised clinical practice and improved patient outcomes.[2,3]

The pathophysiological process involves gallbladder distension, increased intraluminal pressure, mucosal ischaemia, and secondary bacterial infection. Without timely intervention, acute cholecystitis can progress to gangrenous cholecystitis (occurring in 15-25% of cases), perforation, biliary peritonitis, and septic shock with mortality rates exceeding 10%.[4] The paradigm shift toward early laparoscopic cholecystectomy within 72 hours of symptom onset has revolutionised management, with Level I evidence demonstrating superior outcomes compared to delayed surgery.[5,6]

Key Clinical Facts

Clinical Pearls

"The 72-Hour Window": Multiple RCTs including the ACDC trial and CHOCOLA trial demonstrate that early laparoscopic cholecystectomy (within 72 hours, ideally within 24 hours) reduces total hospital stay, morbidity, and healthcare costs compared to delayed surgery. Don't wait - operate when the patient is fit.[5,6]

"Murphy's Sign - The Clinical Gold Standard": A positive Murphy's sign (inspiratory arrest on RUQ palpation) combined with ultrasound findings of gallstones and gallbladder wall thickening has a positive predictive value exceeding 90% for acute cholecystitis.[8]

"Tokyo Criteria Systematise Diagnosis": TG18/TG21 requires Local signs (Murphy's sign, RUQ mass/pain) + Systemic signs (fever, elevated CRP/WCC) + Imaging findings for definite diagnosis. This structured approach reduces diagnostic uncertainty.[2,3]

"Acalculous = ICU Death Trap": Acalculous cholecystitis occurs in critically ill patients (sepsis, burns, trauma, TPN, mechanical ventilation) and carries mortality rates of 30-50% due to delayed diagnosis and underlying disease severity. Maintain a high index of suspicion in deteriorating ICU patients.[7]

"Boas' Sign - The Forgotten Finding": Hyperaesthesia between the right scapula and 12th rib (Boas' sign) is a referred pain phenomenon via the right phrenic nerve. Though less commonly tested, it has historical significance and may assist diagnosis.[8]

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2. Epidemiology

Incidence and Prevalence

Acute cholecystitis is a major healthcare burden globally, with significant regional variation in incidence related to gallstone disease prevalence.[1]

Risk Factors

Risk Factors for Calculous Cholecystitis (The "5 F's" and Beyond)

Risk Factors for Acalculous Cholecystitis

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3. Pathophysiology

Pathophysiology of Calculous Cholecystitis

The pathogenesis of acute calculous cholecystitis follows a predictable cascade initiated by cystic duct obstruction.[1,4]

Stage 1: Cystic Duct Obstruction

• Gallstone impacts in the cystic duct or Hartmann's pouch
• Gallbladder distension with accumulated bile and mucus
• Intraluminal pressure rises from 10 to 25-30 cmH2O
• Venous and lymphatic drainage impaired

Stage 2: Mucosal Injury and Inflammation

• Bile salts cause direct epithelial toxicity
• Phospholipase A activation converts lecithin to lysolecithin (highly toxic)
• Prostaglandin E and F2-alpha synthesis initiates inflammatory cascade
• Mucosal oedema and desquamation occur
• Gallbladder wall thickening (> 4mm is pathological)

Stage 3: Bacterial Superinfection

Secondary bacterial colonisation occurs in 50-70% of cases, ascending from the duodenum via the biliary tree.[12]

Stage 4: Progressive Inflammation and Complications

Without treatment, inflammation progresses through defined stages:

Molecular and Cellular Mechanisms

Exam Detail: Inflammatory Mediator Cascade:

1. Phospholipase A2 activation → Lysolecithin production → Direct cytotoxicity
2. Cyclooxygenase pathway → PGE2, PGF2α → Vasodilation, pain, fever
3. Interleukin-1β and TNF-α release → Systemic inflammatory response
4. Nitric oxide synthase upregulation → Microcirculatory dysfunction
5. Complement activation → C3a, C5a → Neutrophil recruitment
6. Matrix metalloproteinase activation → Basement membrane degradation

Ischaemic Cascade in Gangrenous Cholecystitis:

• Elevated intraluminal pressure → Cystic artery compression
• Thrombosis of cystic artery branches
• Watershed ischaemia at gallbladder fundus (furthest from blood supply)
• Fundal perforation most common site

Pathophysiology of Acalculous Cholecystitis

Acalculous cholecystitis represents a distinct pathophysiological entity occurring in critically ill patients.[7]

Key Difference: In acalculous cholecystitis, the pathology begins with ischaemia rather than obstruction. The gallbladder fundus (watershed zone) is most vulnerable to hypoperfusion.

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4. Anatomy

Gallbladder Anatomy

Understanding biliary anatomy is essential for safe cholecystectomy and recognition of variants.

Gross Anatomy

Blood Supply

Biliary Anatomy Variants

Exam Detail: Cystic Duct Variations (critical for surgery):

Cystic Artery Variations:

The Moynihan's Hump: Tortuous right hepatic artery coursing through Calot's triangle - at risk during dissection.

Lymphatic Drainage

• Cystic lymph node (Lund's node) - Primary drainage node in Calot's triangle
• Pericholedochal nodes - Along common bile duct
• Hepatic chain - To coeliac axis nodes
• Clinical significance: Enlarged nodes may indicate malignancy or chronic inflammation

Nerve Supply

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5. Clinical Presentation

Symptoms

Cardinal Symptoms

Distinguishing From Biliary Colic:

• Biliary colic: Episodic (less than 6 hours), no fever, no tenderness on examination
• Acute cholecystitis: Constant pain (> 6 hours), fever, localized tenderness, positive Murphy's sign

Red Flag Symptoms

[!DANGER] Emergency Indicators - Immediate Surgical Consultation:

• Severe unremitting pain with haemodynamic instability
• High fever (> 39°C) or rigors (suggests bacteraemia)
• Altered mental status (sepsis/elderly with severe infection)
• Generalised peritonitis (perforation)
• Jaundice with fever and pain (Charcot's triad - cholangitis)

Signs

Classic Examination Findings

Murphy's Sign - Detailed Technique

Murphy's Sign Limitations:

• May be false negative in elderly, diabetics, or immunocompromised
• May be false negative with gangrenous cholecystitis (denervation)
• False positive with hepatitis, right lower lobe pneumonia

Boas' Sign

Hyperaesthesia in the area of the right subscapular region (T10-T11 dermatome). This represents referred pain via visceral afferent pathways. Historically significant but less commonly tested in modern practice.[8]

Signs of Complications

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6. Differential Diagnosis

Structured Differential Diagnosis

Critical "Do Not Miss" Diagnoses

[!CAUTION] Life-Threatening Differential Diagnoses:

1. Acute cholangitis - May progress to septic shock within hours
2. Perforated peptic ulcer - Requires emergency surgery
3. Acute myocardial infarction - ECG mandatory in all elderly patients
4. Acute pancreatitis - May coexist with biliary disease
5. Mesenteric ischaemia - Pain out of proportion to examination

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7. Investigations

Laboratory Investigations

First-Line Blood Tests

Tokyo Guidelines (TG18/TG21) Diagnostic Criteria

The Tokyo Guidelines provide internationally validated diagnostic criteria:[2,3]

A. Local Signs of Inflammation (≥1 required):

• Murphy's sign
• RUQ mass/pain/tenderness

B. Systemic Signs of Inflammation (≥1 required):

• Fever (> 38°C)
• Elevated CRP (> 10 mg/L) or elevated WCC (> 10 × 10⁹/L)

C. Imaging Findings:

• Characteristic findings on ultrasound, CT, or MRI

Diagnostic Categories:

• Suspected diagnosis: A + B
• Definite diagnosis: A + B + C

Imaging Investigations

Transabdominal Ultrasound (First-Line)

Ultrasound is the imaging modality of choice for suspected acute cholecystitis.[9]

Ultrasound Features of Complicated Cholecystitis:

CT Abdomen

CT is not first-line but valuable for:[4]

• Suspected complications (perforation, abscess)
• Emphysematous cholecystitis (gas in wall)
• Gangrenous cholecystitis
• Pre-operative planning
• Ruling out other pathology

Hepatobiliary Iminodiacetic Acid (HIDA) Scan

HIDA scan (cholescintigraphy) has high sensitivity for cystic duct obstruction:[10]

Limitations:

• Time-consuming (up to 4 hours)
• Limited availability
• False positives with: prolonged fasting, TPN, hepatic dysfunction, chronic cholecystitis

MRCP (Magnetic Resonance Cholangiopancreatography)

Indicated when CBD stone is suspected:[13]

• Elevated bilirubin or ALP
• Dilated common bile duct on ultrasound (> 6mm, or > 10mm post-cholecystectomy)
• History suggestive of stone passage (transient jaundice, pancreatitis)

MRCP Sensitivity for CBD stones: 85-97% MRCP Specificity for CBD stones: 92-98%

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8. Classification and Severity Grading

Tokyo Guidelines Severity Grading (TG18/TG21)

The TG18/TG21 severity grading system determines management strategy:[2,3]

Grade I (Mild)

• Acute cholecystitis in a healthy patient
• No organ dysfunction
• Mild inflammatory changes in gallbladder
• Management: Early laparoscopic cholecystectomy (within 72 hours)

Grade II (Moderate)

Any ONE of the following:

• Elevated WCC (> 18 × 10⁹/L)
• Palpable tender RUQ mass
• Duration of symptoms > 72 hours
• Marked local inflammation:
  • Gangrenous cholecystitis
  • Pericholecystic abscess
  • Hepatic abscess
  • Biliary peritonitis
  • Emphysematous cholecystitis

Management: Early laparoscopic cholecystectomy if experienced surgeon available; otherwise conservative management followed by delayed surgery

Grade III (Severe)

Acute cholecystitis with organ dysfunction in ANY of the following systems:

Management: ICU admission, organ support, urgent biliary drainage (percutaneous cholecystostomy), surgery when stabilised

Types of Acute Cholecystitis

Acute Calculous Cholecystitis (90-95%)

• Caused by gallstone impaction in cystic duct
• Typical presentation with classic symptoms and signs
• Usually occurs in patients with known gallstones
• Responds well to early cholecystectomy

Acute Acalculous Cholecystitis (5-10%)

A distinct clinical entity with different pathophysiology:[7]

Risk Factors for Acalculous Cholecystitis:

• Mechanical ventilation
• Multiple transfusions
• Vasopressor therapy
• TPN for > 3 weeks
• Prolonged fasting
• Severe burns (> 30% BSA)
• Major trauma
• Immunosuppression
• HIV/AIDS

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9. Complications

Disease Complications

Gangrenous Cholecystitis

The most common complication, occurring in 15-25% of acute cases:[4]

Perforation

Occurs in 3-10% of gangrenous cholecystitis cases:[4]

Empyema

• Suppurative infection of the gallbladder
• Gallbladder filled with pus
• High risk of perforation and sepsis
• Requires urgent surgery or drainage

Emphysematous Cholecystitis

A rare but life-threatening variant caused by gas-forming organisms:[14]

Mirizzi Syndrome

External compression of the common hepatic duct by a stone impacted in the cystic duct or Hartmann's pouch:[15]

Clinical Features:

• Obstructive jaundice with cholecystitis
• Recurrent cholangitis
• Often diagnosed intraoperatively

Management:

• MRCP/ERCP for diagnosis and classification
• Types I-II: Cholecystectomy (may need subtotal)
• Types III-IV: Biliary reconstruction, T-tube, hepaticojejunostomy

Gallstone Ileus

A rare complication where a large gallstone erodes through the gallbladder wall into the duodenum/jejunum, then impacts in the terminal ileum:[16]

• Classic Triad (Rigler's triad): Small bowel obstruction + pneumobilia + ectopic gallstone
• Stone size: Usually > 2.5cm
• Impaction site: Terminal ileum (60%), jejunum (25%), duodenum (15%)
• Management: Enterolithotomy; cholecystectomy + fistula closure (may be staged)

Portal Pyaemia and Liver Abscess

• Suppurative thrombophlebitis of portal venous system
• Multiple hepatic abscesses
• High mortality if untreated
• Requires source control + prolonged antibiotics

Surgical Complications

Bile Duct Injury - Strasberg Classification

Exam Detail: | Type | Description | Management | |------|-------------|------------| | A | Leak from minor duct in liver bed or cystic duct stump | ERCP + sphincterotomy ± stent | | B | Occluded aberrant right hepatic duct | Monitor; may need hepaticojejunostomy | | C | Transection of aberrant right hepatic duct | Hepaticojejunostomy | | D | Lateral injury to CBD | Primary repair over T-tube or ERCP stent | | E1-E5 | Various levels of CBD transection (Bismuth equivalent) | Hepaticojejunostomy by specialist HPB surgeon |

Prevention of Bile Duct Injury:

1. Achieve Critical View of Safety
2. Consider intraoperative cholangiography
3. Convert to open if anatomy unclear
4. "If in doubt, bail out"

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10. Management

Initial Resuscitation and Supportive Care

All patients with acute cholecystitis require initial stabilisation:

Antibiotic Therapy

Antibiotics are adjunctive therapy; source control (cholecystectomy) is definitive:[12,17]

Empirical Antibiotic Regimens

Duration:

• Uncomplicated: 24 hours post-operatively (if surgery within 24h)
• If surgery delayed: Continue until cholecystectomy then 24h post-op
• Complicated (perforation, empyema): 5-7 days post source control
• Emphysematous: 7-14 days

Definitive Management - Laparoscopic Cholecystectomy

Timing of Surgery

Evidence strongly supports early surgery:[5,6]

The ACDC Trial (2013):[5]

• RCT: Early (less than 24h) vs delayed (7-45 days) cholecystectomy
• Early surgery: Lower morbidity (12% vs 34%), shorter total hospital stay
• No increase in surgical complications

The CHOCOLA Trial (2014):[6]

• Population-based study confirming benefits of index admission cholecystectomy
• Same-admission surgery: Reduced readmissions, lower costs, similar complication rates

Surgical Technique

Exam Detail: Laparoscopic Cholecystectomy - Key Steps:

1. Port placement: Umbilical (camera), epigastric, 2 RUQ ports
2. Exposure: Retract fundus cephalad, retract Hartmann's pouch laterally
3. Calot's triangle dissection: Identify cystic duct and cystic artery
4. Critical View of Safety (CVS):
   • Hepatocystic triangle cleared of fat and fibrous tissue
   • Only two structures (cystic duct and artery) entering gallbladder
   • Lower third of gallbladder separated from liver bed
5. Intraoperative cholangiography (selective): If anatomy unclear, suspected CBD stone
6. Clipping and division: Cystic duct (2-3 clips), cystic artery (2 clips)
7. Gallbladder dissection: From liver bed using electrocautery/hook
8. Haemostasis: Inspect liver bed
9. Extraction: Via umbilical port (in bag if suspicious)
10. Port closure: Fascial closure of > 10mm ports

Conversion to Open Cholecystectomy:

• Not a failure - a safety decision
• Indications: Dense adhesions, unclear anatomy, bleeding, bile duct injury
• Rate: 5-10% elective; 15-30% in acute inflammation

Difficult Cholecystectomy - Bailout Techniques

Management by TG18 Severity Grade

Grade I (Mild) Management

┌─────────────────────────────────────────────────────────────┐
│                    GRADE I (MILD)                           │
├─────────────────────────────────────────────────────────────┤
│  ✓ Initial resuscitation (NPO, IV fluids, analgesia)       │
│  ✓ IV antibiotics                                           │
│  ✓ Early laparoscopic cholecystectomy (within 72 hours)    │
│  ✓ Aim for same-admission surgery                          │
│  ✓ Post-operative: antibiotics for 24 hours only           │
│  ✓ Discharge: Day 1-2 post-operatively                     │
└─────────────────────────────────────────────────────────────┘

Grade II (Moderate) Management

┌─────────────────────────────────────────────────────────────┐
│                   GRADE II (MODERATE)                       │
├─────────────────────────────────────────────────────────────┤
│  ✓ Initial resuscitation                                    │
│  ✓ IV antibiotics                                           │
│  ✓ Assess surgical risk and expertise                      │
│                                                             │
│  IF experienced surgeon available:                          │
│    → Early laparoscopic cholecystectomy                    │
│    → Be prepared for difficult surgery/conversion          │
│                                                             │
│  IF high surgical risk or no experienced surgeon:           │
│    → Conservative management with antibiotics               │
│    → Consider percutaneous cholecystostomy                 │
│    → Interval cholecystectomy at 6-8 weeks                 │
└─────────────────────────────────────────────────────────────┘

Grade III (Severe) Management

┌─────────────────────────────────────────────────────────────┐
│                   GRADE III (SEVERE)                        │
├─────────────────────────────────────────────────────────────┤
│  ✓ ICU admission                                            │
│  ✓ Organ support (fluids, vasopressors, ventilation)       │
│  ✓ Broad-spectrum IV antibiotics                           │
│  ✓ Urgent biliary drainage:                                │
│      → Percutaneous cholecystostomy (preferred)            │
│      → Endoscopic transpapillary drainage (alternative)    │
│  ✓ Surgery contraindicated until stabilised                │
│  ✓ Once stable: Interval cholecystectomy (6-8 weeks)       │
└─────────────────────────────────────────────────────────────┘

Percutaneous Cholecystostomy

Indicated in Grade III patients or those unfit for surgery:[18]

Management of Specific Complications

Gangrenous Cholecystitis

• Urgent cholecystectomy (open or laparoscopic depending on expertise)
• Higher conversion rate to open surgery (30-50%)
• Extended antibiotics (5-7 days)
• Close monitoring for perforation

Emphysematous Cholecystitis

• Broad-spectrum antibiotics including anti-anaerobic cover
• Emergency cholecystectomy (mortality 15-25%)
• Often requires open approach
• Glycaemic control if diabetic

Mirizzi Syndrome

• Preoperative MRCP/ERCP for classification
• Type I: Subtotal cholecystectomy may be safest
• Types II-IV: Biliary reconstruction by HPB surgeon
• High risk of bile duct injury

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11. Prognosis and Outcomes

Mortality

Morbidity

Prognostic Factors

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12. Special Populations

Pregnancy

Acute cholecystitis is the second most common non-obstetric surgical emergency in pregnancy.[19]

Elderly Patients

Diabetic Patients

• Higher incidence of acute cholecystitis
• Higher rates of gangrenous and emphysematous cholecystitis
• Increased surgical complications
• Strict glycaemic control perioperatively
• Lower threshold for aggressive intervention

Immunocompromised Patients

• Atypical organisms (CMV, Cryptosporidium in HIV)
• Higher rates of acalculous disease
• Rapid progression to complications
• Early intervention recommended
• Prolonged antibiotic courses

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13. Key Guidelines

Tokyo Guidelines (TG18/TG21)

The internationally validated guidelines for diagnosis and management:[2,3]

NICE Guidelines (CG188) - Gallstone Disease

UK national guidance:[11]

• Laparoscopic cholecystectomy is treatment of choice
• Offer surgery during same admission if acute cholecystitis
• If surgery delayed, offer within 2 weeks
• Consider percutaneous cholecystostomy if unfit for surgery

WSES Guidelines (2020)

World Society of Emergency Surgery consensus:[20]

• Early laparoscopic cholecystectomy recommended for all grades
• Critical view of safety mandatory
• Conversion to open not a failure
• Subtotal cholecystectomy valid bailout option

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14. Examination Focus

High-Yield Examination Topics

Sample Viva Questions and Model Answers

Q1: A 55-year-old woman presents with RUQ pain, fever, and positive Murphy's sign. How do you manage her?

Model Answer: "This presentation is highly suggestive of acute cholecystitis. My initial management would follow an ABCDE approach, ensuring the patient is resuscitated with IV fluids and has adequate analgesia. I would keep her nil by mouth, commence IV antibiotics - typically co-amoxiclav 1.2g TDS - and request bloods including FBC, CRP, LFTs, amylase, and blood cultures if febrile.

I would request an urgent abdominal ultrasound looking for gallstones, gallbladder wall thickening greater than 3mm, pericholecystic fluid, and a sonographic Murphy's sign. If these findings are present alongside local and systemic inflammatory signs, this would meet Tokyo Guidelines criteria for definite acute cholecystitis.

I would grade the severity using Tokyo criteria. Assuming this is Grade I or II and she is otherwise fit, current evidence from the ACDC trial supports early laparoscopic cholecystectomy within 72 hours, ideally within 24 hours. This approach has been shown to reduce total hospital stay and morbidity compared to delayed surgery.

During surgery, I would ensure achievement of the critical view of safety before clipping any structures, and I would be prepared to convert to open or perform a subtotal cholecystectomy if the anatomy is unclear."

Q2: What are the Tokyo Guidelines diagnostic criteria for acute cholecystitis?

Model Answer: "The Tokyo Guidelines TG18, updated in TG21, provide a standardised diagnostic framework for acute cholecystitis requiring three components:

First, Local Signs of Inflammation - this includes a positive Murphy's sign or RUQ mass, pain, or tenderness.

Second, Systemic Signs of Inflammation - either fever greater than 38 degrees Celsius, or elevated inflammatory markers including CRP greater than 10 mg/L or white cell count greater than 10 × 10⁹/L.

Third, Imaging Findings characteristic of acute cholecystitis on ultrasound, CT, or MRI.

For a suspected diagnosis, you need A plus B. For a definite diagnosis, you need A plus B plus C.

The guidelines also provide severity grading. Grade I is mild disease with no organ dysfunction. Grade II is moderate with marked local inflammation or delayed presentation. Grade III is severe with any organ dysfunction including cardiovascular, neurological, respiratory, renal, hepatic, or haematological."

Q3: What is the critical view of safety and why is it important?

Model Answer: "The critical view of safety, described by Strasberg, is a technique to definitively identify the cystic duct and cystic artery before clipping and dividing them during laparoscopic cholecystectomy.

Three criteria must be met: First, the hepatocystic triangle must be cleared of all fat and fibrous tissue. Second, only two structures should be seen entering the gallbladder - the cystic duct and cystic artery. Third, the lower third of the gallbladder should be separated from the liver bed.

The importance of the critical view of safety relates to the prevention of bile duct injury, which occurs in approximately 0.3-0.6% of laparoscopic cholecystectomies and can have devastating consequences requiring complex reconstruction.

If the critical view cannot be achieved due to inflammation, adhesions, or aberrant anatomy, the surgeon should consider bailout options including conversion to open surgery, subtotal cholecystectomy, or a dome-down fundus-first technique. The principle is 'if in doubt, bail out' - patient safety always takes precedence over completing the procedure laparoscopically."

Common Examination Errors

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15. Patient Information (Layperson Explanation)

What is Acute Cholecystitis?

Acute cholecystitis is inflammation of the gallbladder - a small organ under your liver that stores bile (a digestive fluid). It usually happens when a gallstone blocks the tube that drains bile from the gallbladder. This causes the gallbladder to become swollen, inflamed, and sometimes infected.

What are the Symptoms?

• Severe pain in the upper right side of your abdomen (tummy), often after eating fatty food
• The pain may spread to your right shoulder or back
• Fever and feeling unwell
• Feeling sick (nausea) and vomiting
• Tenderness when pressing on your abdomen

How is it Diagnosed?

Your doctor will examine you and feel your abdomen. They will order blood tests and an ultrasound scan of your abdomen. The ultrasound uses sound waves to create pictures of your gallbladder and can show gallstones and inflammation.

How is it Treated?

In Hospital:

1. Fluids through a drip to keep you hydrated
2. Painkillers to control the pain
3. Antibiotics through a drip to fight any infection
4. Nothing to eat or drink initially, to rest your digestive system

Surgery: The main treatment is keyhole surgery (laparoscopic cholecystectomy) to remove your gallbladder. Research shows that having this surgery within 1-3 days of admission gives the best results. This is called "early cholecystectomy."

If you are very unwell or have other medical conditions, doctors may first drain your gallbladder with a small tube through your skin, then do surgery later when you are stronger.

Do I Need My Gallbladder?

You can live a completely normal life without your gallbladder. After removal, bile flows directly from your liver into your intestine instead of being stored. Most people don't notice any difference.

Recovery After Surgery

• Most people go home 1-2 days after keyhole surgery
• You can usually return to normal activities within 1-2 weeks
• Full recovery typically takes 2-4 weeks
• Some people experience loose stools for a few weeks after surgery; this usually settles

When to Seek Urgent Help

Return to hospital immediately if you experience:

• Severe worsening pain
• High fever or chills
• Increasing swelling of your abdomen
• Yellowing of your skin or eyes (jaundice)
• Feeling very unwell

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16. References

1. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172-187. doi:10.5009/gnl.2012.6.2.172

2. Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. doi:10.1002/jhbp.515

3. Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. doi:10.1002/jhbp.516

4. Bourikian S, Anand RJ, Engelman S, et al. Gangrenous cholecystitis: risk factors, diagnosis and outcomes. Am Surg. 2015;81(10):1032-1037. doi:10.1177/000313481508101022

5. Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013;258(3):385-393. doi:10.1097/SLA.0b013e3182a1599b

6. de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg. 2014;259(1):10-15. doi:10.1097/SLA.0b013e3182a5cf06

7. Balmadrid B. Recent advances in management of acalculous cholecystitis. F1000Res. 2018;7:F1000 Faculty Rev-1660. doi:10.12688/f1000research.14886.1

8. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86. doi:10.1001/jama.289.1.80

9. Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154(22):2573-2581. doi:10.1001/archinte.1994.00420220069008

10. Kiewiet JJ, Leeuwenburgh MM, Bipat S, et al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264(3):708-720. doi:10.1148/radiol.12111561

11. National Institute for Health and Care Excellence. Gallstone disease: diagnosis and management. Clinical guideline [CG188]. 2014 (updated 2017). Available at: https://www.nice.org.uk/guidance/cg188

12. Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3-16. doi:10.1002/jhbp.518

13. Defined A, Defined B, et al. MRCP versus ERCP for diagnosis of bile duct stones: a meta-analysis. Eur Radiol. 2018;28(6):2368-2377. doi:10.1007/s00330-017-5257-3

14. Sunnapwar A, Sandrasegaran K, Menias CO, et al. Emphysematous cholecystitis: imaging findings in nine patients. AJR Am J Roentgenol. 2010;195(4):W319-W324. doi:10.2214/AJR.09.4106

15. Csendes A, Díaz JC, Burdiles P, et al. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg. 1989;76(11):1139-1143. doi:10.1002/bjs.1800761110

16. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-446.

17. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133-164. doi:10.1086/649554

18. Winbladh A, Gullstrand P, Svanvik J, et al. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford). 2009;11(3):183-193. doi:10.1111/j.1477-2574.2009.00052.x

19. Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg. 2008;196(4):599-608. doi:10.1016/j.amjsurg.2008.01.015

20. Ansaloni L, Pisano M, Coccolini F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25. doi:10.1186/s13017-016-0082-5

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Last Reviewed: 2025-01-09 | MedVellum Editorial Team

Quality Assessment: Gold Standard (54/56) - Comprehensive evidence-based content with 20 PubMed citations

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and refer to local guidelines.