Acute cholecystitis

Last reviewed: 6 Sep 2022
Last updated: 05 May 2022



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
Full details

Other diagnostic factors

  • fever/chills
  • nausea
  • right shoulder pain
  • anorexia
  • vomiting
  • jaundice
Full details

Risk factors

  • gallstones
  • physical inactivity
  • low fibre intake
  • severe illness
  • trauma
  • severe burns
  • total parenteral nutrition (TPN)
  • diabetes
  • ceftriaxone
  • ciclosporin
  • hepatic arterial embolisation
  • infections
Full details

Diagnostic investigations

1st investigations to order

  • CT or MRI of the abdomen
  • abdominal ultrasound
  • FBC
  • CRP
  • bilirubin
  • LFTs
  • serum lipase or amylase
  • blood cultures and/or bile cultures
Full details

Investigations to consider

  • magnetic resonance cholangiopancreatography (MRCP)
  • endoscopic ultrasound (EUS)
Full details

Treatment algorithm


associated organ dysfunction (severe; Tokyo guideline grade III)

no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or II)


Expert advisers

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.

Peer reviewers

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.


Emma Quigley,

Section Editor, BMJ Best Practice


EQ declares that she has no competing interests.

Sue Mayor,

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.

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice


TAO declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice


JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

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