Acute cholecystitis is a major complication of cholelithiasis (i.e., gallstones); symptomatic gallstones are common before developing cholecystitis.
Patients typically present with pain and localised tenderness, with or without guarding, in the upper right quadrant.
There may be evidence of a systemic inflammatory response with fever, elevated white cell count, and raised C-reactive protein.
Ultrasound is the definitive initial test. Magnetic resonance cholangiopancreatography may be required. In a patient with suspected sepsis, use computed tomography (or magnetic resonance imaging)to identify the cause.
Treatment is with antibiotics, analgesia, and fluid resuscitation as required, likely to be followed by an early cholecystectomy.
Acute cholecystitis is acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones. It develops in up to 10% of patients with symptomatic gallstones. In most cases (90%), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall. In 5% of cases, bile inspissation (due to dehydration) or bile stasis (due to trauma or severe systemic illness) can block the cystic duct, causing an acalculous cholecystitis.
History and exam
Key diagnostic factors
- pain in the upper right quadrant
- tenderness in the right upper quadrant
- signs and symptoms of inflammation
- palpable mass
- presence of risk factors
Other diagnostic factors
- right shoulder pain
- physical inactivity
- low fibre intake
- severe illness
- severe burns
- total parenteral nutrition (TPN)
- hepatic arterial embolisation
1st investigations to order
- CT or MRI of the abdomen
- abdominal ultrasound
- serum lipase or amylase
- blood cultures and/or bile cultures
Investigations to consider
- magnetic resonance cholangiopancreatography (MRCP)
- endoscopic ultrasound (EUS)
associated organ dysfunction (severe; Tokyo guideline grade III)
no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or II)
John Abercrombie, FRCS
General and Colorectal Surgeon
Queen's Medical Centre
JA is Clinical Lead for General Surgery, Getting It Right First Time.
JA is a council member of the Royal College of Surgeons of England. He also provides expert advice to Spire Healthcare on clinical management of selected cases and on improving processes for review of cases resulting in mortality.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:
Charles Bellows MD
Professor of Surgery
University of New Mexico School of Medicine
CB is an author of one study referenced in this topic. CB declares that he has no other competing interests.
Christian Macutkiewicz, MD, FHEA, FRCS
Consultant General and Hepato-Pancreato-Biliary Surgeon
Clinical Lead for Emergency General Surgery, Gastrointestinal Medicine, and Surgery CSU
Manchester Royal Infirmary
Director of Scientific Programme
Association of Surgeons of Great Britain and Ireland
CM declares that he has no competing interests.
Section Editor, BMJ Best Practice
EQ declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including NICE, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, NCEPOD, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare, and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.
Lead Section Editor, BMJ Best Practice
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Comorbidities Editor, BMJ Best Practice
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Drug Editor, BMJ Best Practice
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- Acute cholangitis
- Chronic cholecystitis
- Peptic ulcer disease
- Pathway for the management of acute gallstone diseases
- Gallstone disease: diagnosis and management
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