Acute Cholecystitis
Summary
Acute cholecystitis is inflammation of the gallbladder, most commonly caused by gallstone impaction in the cystic duct (calculous cholecystitis; ~90% of cases). Obstruction leads to gallbladder distension, mucosal ischaemia, bacterial infection, and progressive inflammation. The classic presentation is Murphy's sign positive with right upper quadrant pain, fever, and leukocytosis. Ultrasound is the imaging modality of choice, showing gallstones, wall thickening, and pericholecystic fluid. The Tokyo Guidelines (TG18) provide standardised diagnostic criteria and severity grading. Current evidence strongly supports early laparoscopic cholecystectomy (ideally within 72 hours if haemodynamically stable) as first-line treatment. For high-risk patients unfit for surgery, percutaneous cholecystostomy provides source control until definitive surgery can be performed.
Key Facts
- Aetiology: 90% calculous (gallstones); 10% acalculous (critically ill, TPN, burns)
- Murphy's sign: Inspiratory arrest on RUQ palpation — 65% sensitive, 87% specific
- Ultrasound findings: Gallstones, wall thickening >3mm, pericholecystic fluid, sonographic Murphy's
- Tokyo criteria: Definite diagnosis = Local signs + Systemic signs + Imaging findings
- Treatment: Early laparoscopic cholecystectomy (within 72 hours is optimal)
- Mortality: <1% for uncomplicated; up to 10% for gangrenous/perforated
- Complications: Gangrene (15-20%), perforation, empyema, cholangitis
- Acalculous cholecystitis: 5-10% of cases; ICU patients; high mortality
Clinical Pearls
"Early Surgery Saves Lives": Landmark trials (ACDC, CHOCOLA) show early cholecystectomy (<72h) is superior to delayed surgery. Don't wait — operate when fit, preferably on index admission.
"Murphy's Sign = Positive Predictive Gold": A positive Murphy's sign (inspiration arrested by examiner's hand pressing on RUQ) has high specificity. If positive with stones on ultrasound, diagnosis is almost certain.
"The Tokyo Criteria Systematise Diagnosis": TG18 requires local signs (Murphy's, RUQ mass) + systemic signs (fever, raised WCC/CRP) + imaging evidence (US findings) for definite diagnosis.
"Acalculous = ICU Death Trap": Acalculous cholecystitis occurs in critically ill patients (sepsis, burns, TPN, post-op). It has high mortality (up to 50%) due to delayed diagnosis. Maintain high index of suspicion.
"Cholecystostomy Is a Bridge": Percutaneous cholecystostomy is a life-saving temporising measure in the unfit patient. It provides source control — definitive surgery (interval cholecystectomy) follows once patient is optimised.
Why This Matters Clinically
Acute cholecystitis is one of the most common surgical emergencies. Prompt recognition and treatment prevent life-threatening complications (gangrene, perforation, sepsis). The shift towards early surgery has improved outcomes significantly. Every clinician should be able to recognise the clinical features, interpret ultrasound findings, initiate appropriate management, and refer urgently for surgical assessment.[1,2]
Incidence & Prevalence
| Parameter | Data |
|---|---|
| Gallstone prevalence | 10-15% of adults have gallstones |
| Lifetime cholecystitis risk | 1-4% of patients with gallstones develop cholecystitis/year |
| Cholecystectomy volume | ~70,000 per year in UK |
| Peak age | 50-70 years |
| Sex ratio | F:M = 3:1 (for gallstones); less disparity for cholecystitis |
Risk Factors
| Factor | Notes |
|---|---|
| Gallstones | Present in 90% (calculous cholecystitis) |
| Female sex | Higher gallstone prevalence |
| Age | Increasing age |
| Obesity | Increased cholesterol stones |
| Rapid weight loss | Predisposes to stone formation |
| Pregnancy / Multiparity | Hormonal effects on bile composition |
| Diabetes mellitus | Increased risk of complicated cholecystitis |
| Critical illness | Acalculous cholecystitis risk |
| TPN | Bile stasis |
| Immunosuppression | Atypical presentations, increased complications |
Mechanism (Calculous)
Step 1: Cystic Duct Obstruction
- Gallstone impacts in cystic duct
- Gallbladder distension with bile
- Increased intraluminal pressure
Step 2: Mucosal Injury
- Bile salts cause direct mucosal damage
- Prostaglandin release → Inflammation
- Phospholipase A activation → Lysolecithin (toxic to mucosa)
Step 3: Bacterial Infection
- Secondary bacterial colonisation (ascending from duodenum)
- Common organisms: E. coli, Klebsiella, Enterococcus
- Suppurative inflammation
Step 4: Progressive Inflammation
- Gallbladder wall oedema and thickening
- Vascular compromise → Ischaemia → Gangrene (15-20%)
- Perforation if untreated (~10% of gangrenous cases)
Acalculous Cholecystitis
| Feature | Details |
|---|---|
| Definition | Cholecystitis without gallstones |
| Setting | Critical illness, ICU, post-major surgery, burns, sepsis, TPN |
| Mechanism | Bile stasis + ischaemia + impaired gallbladder motility |
| Mortality | Very high (up to 50%) due to delayed diagnosis and underlying disease |
| Diagnosis | High index of suspicion; US may show sludge, wall thickening |
Complications Pathway
| Complication | Risk | Features |
|---|---|---|
| Gangrenous cholecystitis | 15-20% | Necrotic wall; may perforate |
| Perforation | 3-10% (of gangrenous) | Localised abscess or free perforation |
| Empyema | Variable | Pus-filled gallbladder |
| Cholecystoenteric fistula | Rare | Gallstone ileus if stone passes |
| Mirizzi syndrome | Rare | Stone in cystic duct compressing CHD |
Symptoms
| Symptom | Frequency | Notes |
|---|---|---|
| RUQ pain | 95% | Constant, severe, radiating to scapula |
| Fever | 50-70% | May be absent in elderly/immunosuppressed |
| Nausea/vomiting | 60-70% | Common |
| Anorexia | Common | Non-specific |
| Previous biliary colic | 50% | Prior episodes of RUQ pain post-fatty meal |
Signs
| Sign | Sensitivity | Specificity | Notes |
|---|---|---|---|
| Murphy's sign | 65% | 87% | Inspiratory arrest on RUQ palpation |
| RUQ tenderness | 95% | Variable | May have guarding |
| Fever >38°C | 50% | Variable | May be absent |
| Palpable gallbladder | <10% | High | Suggests empyema/distension |
| Jaundice | 15-20% | — | Suggests CBD stone or Mirizzi syndrome |
Red Flags
[!CAUTION] Red Flags — Severe/Complicated Cholecystitis:
- Sepsis or septic shock (hypotension, tachycardia, altered mental status)
- High persistent fever despite antibiotics
- Peritoneal signs (guarding, rigidity, rebound)
- Crepitus over RUQ (emphysematous cholecystitis — gas-forming organisms)
- Marked leukocytosis (>18 × 10⁹/L)
- Organ dysfunction (renal, hepatic, cardiovascular)
- Failure to improve within 24-48 hours of treatment
Systematic Approach
General Inspection:
- Unwell appearance (septic)
- Fever, tachycardia
- Jaundice (suggests CBD involvement)
Abdominal Examination:
- Inspection: Distension (localised or generalised)
- Palpation:
- Murphy's sign: Place hand at costal margin in RUQ; ask patient to inspire; positive if inspiration interrupted by pain
- RUQ tenderness with guarding
- Palpable gallbladder (rare)
- Peritonism (suggests perforation)
- Percussion: May be tender; resonance normal unless perforated
- Auscultation: Bowel sounds usually present
Murphy's Sign Technique
| Step | Action |
|---|---|
| 1 | Position patient supine |
| 2 | Place examining hand at RUQ costal margin |
| 3 | Apply gentle pressure over gallbladder area |
| 4 | Ask patient to take deep breath in |
| 5 | Positive: Patient catches breath due to pain (inflamed gallbladder descends onto examining hand) |
| 6 | Compare with LUQ (Murphy's should be negative on left) |
First-Line Investigations
| Investigation | Findings | Notes |
|---|---|---|
| FBC | Leukocytosis (>10 × 10⁹/L) | May be very high in gangrenous |
| CRP | Elevated | Inflammatory marker |
| LFTs | Usually normal; mild bilirubin rise if CBD stone | AST/ALT↑ suggests CBD stone passage |
| Amylase/Lipase | Normal (unless pancreatitis) | Exclude gallstone pancreatitis |
| U&E | Usually normal | Check AKI in sepsis |
| Blood cultures | Positive in 20-30% | If pyrexial/septic |
Imaging
| Modality | Sensitivity | Findings |
|---|---|---|
| Ultrasound (US) | 90-95% | Gallstones, wall thickening >3mm, pericholecystic fluid, sonographic Murphy's, sludge |
| CT Abdomen | 85-90% | Wall thickening, gas in wall (emphysematous), abscess, perforation |
| HIDA Scan | 95-98% | Non-visualisation of gallbladder = cystic duct obstruction; rarely used acutely |
| MRCP | For CBD assessment | If bilirubin elevated, assess for choledocholithiasis |
Tokyo Guidelines Diagnostic Criteria (TG18)
A — Local Signs of Inflammation:
- Murphy's sign
- RUQ mass/pain/tenderness
B — Systemic Signs of Inflammation:
- Fever (>38°C)
- Elevated CRP
- Elevated WCC
C — Imaging Findings:
- Characteristic US/CT findings
Diagnosis:
- Suspected: A + B
- Definite: A + B + C
Management Algorithm
ACUTE CHOLECYSTITIS
↓
┌──────────────────────────────────────────────────────────────┐
│ INITIAL RESUSCITATION │
├──────────────────────────────────────────────────────────────┤
│ ➤ NBM │
│ ➤ IV fluids (crystalloid) │
│ ➤ IV analgesia (paracetamol, opioids PRN) │
│ ➤ IV antibiotics (co-amoxiclav or piperacillin-tazobactam) │
│ ➤ Blood cultures if pyrexial │
│ ➤ VTE prophylaxis │
└──────────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────────┐
│ SEVERITY GRADING (TG18) │
├──────────────────────────────────────────────────────────────┤
│ Grade I (Mild): No organ dysfunction; healthy patient │
│ Grade II (Moderate): Any of: WCC >18, palpable RUQ mass, │
│ symptoms >72h, marked local inflam │
│ Grade III (Severe): Organ dysfunction (CV, neuro, resp, │
│ renal, hepatic, haematological) │
└──────────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────────┐
│ SURGICAL MANAGEMENT │
├──────────────────────────────────────────────────────────────┤
│ GRADE I (Mild) & GRADE II (Moderate): │
│ ➤ Early laparoscopic cholecystectomy (within 72 hours) │
│ ➤ Same admission surgery preferred │
│ │
│ GRADE III (Severe): │
│ ➤ Stabilise and resuscitate in ICU │
│ ➤ If unfit for surgery: │
│ • Percutaneous cholecystostomy (PC) │
│ • Interval cholecystectomy once fit (~6 weeks) │
│ ➤ If fit and responding: │
│ • May attempt early cholecystectomy │
├──────────────────────────────────────────────────────────────┤
│ SURGICAL OPTIONS: │
│ ➤ Laparoscopic cholecystectomy (first-line) │
│ ➤ Open cholecystectomy (if laparoscopic not feasible) │
│ ➤ Subtotal cholecystectomy (severely inflamed/difficult) │
└──────────────────────────────────────────────────────────────┘
Antibiotic Regimens
| Regimen | Dose | Notes |
|---|---|---|
| Co-amoxiclav | 1.2g TDS IV | First-line; covers common biliary organisms |
| Piperacillin-tazobactam | 4.5g TDS IV | If more severe or healthcare-associated |
| Ciprofloxacin + Metronidazole | 400mg BD + 500mg TDS | Beta-lactam allergy |
| Duration | 24-48h post-surgery if uncomplicated | Longer if complicated (gangrene, perforation) |
Timing of Surgery (Evidence-Based)
| Timing | Outcome |
|---|---|
| Early (<72 hours) | Preferred; lower morbidity, shorter LOS, fewer complications |
| Same index admission | Best outcomes; prevents recurrent attacks while waiting |
| Delayed (>7 days, interval) | Higher conversion rates; indicated only if unfit for early surgery |
Surgical Complications
| Complication | Incidence | Management |
|---|---|---|
| Bile duct injury | 0.3-0.6% | Recognition and repair; may need ERCP/stent |
| Bile leak | 0.5-1% | ERCP + stent; drain if collection |
| Conversion to open | 5-10% | Higher in difficult/gangrenous cases |
| Bleeding | 1% | Haemostasis; transfusion if significant |
| Wound infection | 1-2% | Antibiotics; drainage |
Disease Complications
| Complication | Incidence | Features |
|---|---|---|
| Gangrenous cholecystitis | 15-20% | Necrosis of gallbladder wall; perforation risk |
| Perforation | 3-10% | Localised abscess or generalised peritonitis |
| Empyema | 5% | Pus-filled gallbladder |
| Cholecystoenteric fistula | Rare | Erosion into duodenum; may cause gallstone ileus |
| Mirizzi syndrome | Rare | Stone in cystic duct compressing CHD → jaundice |
Mortality
| Category | Mortality |
|---|---|
| Uncomplicated calculous | <1% |
| Gangrenous | 5-10% |
| Perforated | 10-15% |
| Acalculous | Up to 50% (due to underlying critical illness) |
Prognostic Factors
| Good Prognosis | Poor Prognosis |
|---|---|
| Early presentation | Delayed presentation |
| Uncomplicated disease | Gangrenous/perforated |
| Early surgery | Delayed/interval surgery |
| Young, fit patient | Elderly, multiple comorbidities |
| Calculous | Acalculous (ICU setting) |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| Tokyo Guidelines (TG18) | Japanese Society | 2018 | Diagnostic criteria, severity grading, management |
| NICE Gallstone Disease (CG188) | NICE | 2014 (updated 2017) | Recommends laparoscopic cholecystectomy |
| WSES Guidelines | World Society Emergency Surgery | 2020 | Emergency surgery pathway |
Landmark Trials
ACDC Trial (Gutt et al. 2013)
- RCT: Early (<24h) vs delayed (7-45 days) laparoscopic cholecystectomy
- Early surgery: Lower morbidity, shorter hospital stay
- PMID: 23897963
CHOCOLA Trial (de Mestral et al. 2014)
- Population-based study supporting early cholecystectomy
- Same-admission surgery reduces total costs and readmissions
- PMID: 24859201
Evidence Strength
| Intervention | Level | Evidence |
|---|---|---|
| Early laparoscopic cholecystectomy | 1a | RCTs, meta-analyses |
| Antibiotics for acute cholecystitis | 2a | Cohort/observational |
| Percutaneous cholecystostomy (high-risk) | 2b | Cohort studies |
What is Acute Cholecystitis?
Acute cholecystitis is inflammation of the gallbladder — a small organ under your liver that stores bile. It usually happens when a gallstone blocks the tube that drains bile from the gallbladder.
What are the symptoms?
- Severe pain in the upper right side of your tummy (often after eating fatty food)
- The pain may spread to your right shoulder or back
- Fever
- Feeling sick and vomiting
How is it treated?
Treatment involves:
- Hospital admission: You'll need fluids through a drip and antibiotics
- Surgery: Keyhole surgery (laparoscopic cholecystectomy) to remove your gallbladder — usually done within 1-3 days
- If you're very unwell: A drain may be placed temporarily, with surgery later
Do I need my gallbladder?
The gallbladder stores bile, but you can live perfectly well without it. After removal, bile flows directly from the liver into the intestine.
Recovery
Most people go home 1-2 days after keyhole surgery and fully recover within 1-2 weeks.
Guidelines
-
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. PMID: 29090866
-
NICE. Gallstone disease: diagnosis and management (CG188). 2014 (updated 2017). nice.org.uk
Key Trials
-
Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy. Ann Surg. 2013;258(3):385-393. PMID: 23897963
-
de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis. Ann Surg. 2014;259(1):10-15. PMID: 24859201
High-Yield Exam Topics
| Topic | Key Points |
|---|---|
| Murphy's sign | Inspiratory arrest on RUQ palpation; 65% sens, 87% spec |
| US findings | Stones, wall >3mm, pericholecystic fluid, sonographic Murphy's |
| Tokyo criteria | Local + Systemic + Imaging = Definite diagnosis |
| Treatment timing | Early cholecystectomy (<72h) is superior |
| Acalculous cholecystitis | ICU patients; high mortality; high suspicion needed |
| Cholecystostomy | Bridge to surgery in unfit patients |
Sample Viva Questions
Q1: A 55-year-old presents with RUQ pain, fever, and positive Murphy's sign. How do you manage?
Model Answer: This presentation is consistent with acute cholecystitis. Initial management: NBM, IV fluids, IV antibiotics (co-amoxiclav), analgesia. I would request bloods (FBC, LFTs, amylase, CRP) and urgent abdominal ultrasound. If US confirms cholecystitis (gallstones + wall thickening + pericholecystic fluid), I would grade severity using Tokyo criteria and refer for early laparoscopic cholecystectomy — ideally within 72 hours if patient is stable. If severely unwell or unfit for surgery, I would discuss percutaneous cholecystostomy as a bridging option.
Q2: What is the evidence for early vs delayed cholecystectomy?
Model Answer: Multiple RCTs (ACDC, CHOCOLA) and meta-analyses show early laparoscopic cholecystectomy (within 72 hours) is superior to delayed surgery (>7 days). Benefits include shorter total hospital stay, lower morbidity, fewer readmissions (while waiting for interval surgery), and no increased complication rate despite operating on an inflamed gallbladder.
Q3: What is Murphy's sign and how do you elicit it?
Model Answer: Murphy's sign is inspiratory arrest caused by contact between the inflamed gallbladder and the examiner's hand. Technique: With the patient supine, place your hand at the RUQ (subcostal), apply gentle pressure, and ask the patient to take a deep breath in. Positive if pain causes the patient to suddenly stop inspiring. Compare with the left side (should be negative). It has ~65% sensitivity and ~87% specificity for acute cholecystitis.
Common Exam Errors
| Error | Correct Approach |
|---|---|
| Recommending delayed surgery | Early cholecystectomy (<72h) is evidence-based and superior |
| Forgetting to compare with left side | Murphy's sign should be positive on right, negative on left |
| Missing acalculous cholecystitis | Consider in ICU patients with unexplained sepsis |
| Not checking LFTs | Raised bilirubin/ALP suggests CBD stone (consider MRCP/ERCP) |
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.