History and exam

Key diagnostic factors


pain in the upper right quadrant

Establish whether there is pain in the right upper quadrant. A constant pain present for several hours is consistent with cholecystitis.[3][27][34]

  • The pain is severe and steady.

  • Duration of pain can be shorter if the gallstone returns into the gallbladder lumen or passes into the duodenum.

  • Pain may radiate to the back.

tenderness in the right upper quadrant

Examine for tenderness in the right upper quadrant:[3][27][34]

  • With or without Murphy’s sign

  • With or without a palpable mass.

Practical tip

There are limitations to Murphy’s sign (rest your hand along the costal margin and assess whether deep inspiration causes pain). It has a high sensitivity but low specificity.[44] It is particularly unreliable in older adults. This physical sign must be elicited with gentleness; it relies on causing the patient pain, which should be minimised.

signs and symptoms of inflammation

Test to confirm inflammatory markers. Raised inflammatory markers indicate infection or inflammation of the gallbladder and are a guide to severity.

  • Signs of inflammation include:[34]

    • Fever

    • Elevated white cell count

    • Elevated CRP

    • Elevated erythrocyte sedimentation rate.

palpable mass

Palpate the abdomen. A distended, tender gallbladder may be palpable as a distinct mass.[11][34] 

Guidelines from the UK National Institute for Health and Care Excellence on recognition of and referral for suspected cancer recommend:[36]

  • Considering an urgent direct access ultrasound scan, to be performed within 2 weeks, to assess for gallbladder cancer or liver cancer in patients with an abdominal mass consistent with an enlarged gallbladder or an enlarged liver

  • Considering a suspected cancer pathway referral, for an appointment within 2 weeks, for patients with an upper abdominal mass consistent with stomach cancer.

presence of risk factors

Cover the following risk factors to help assess the likelihood of cholecystitis.

  • Gallstones

    • About 90% of acute cholecystitis patients have gallstones.[2][3]

  • Previous episode of biliary pain

    • About 50% of patients who have had 1 episode of biliary pain will have another within 1 year.[37]

  • Severe illness

    • Gallbladder dysmotility or ischaemia may occur in critically ill patients, increasing the risk of cholecystitis.[6]

  • Physical activity level

    • Being physically active may provide some protection against gallstone disease generally.[24]

  • Ceftriaxone

    • Causes precipitation of calcium salts into bile.[39]

  • Ciclosporin

    • Can decrease bile acid secretion, which may predispose to sludge or stone formation.[11]

  • Risk factors for acalculous cholecystitis:[3] 

    • Severe trauma or burns – patients with extensive burns commonly have multiple risk factors for developing acalculous cholecystitis, such as sepsis, dehydration, total parenteral nutrition use, and positive pressure ventilation[19] 

    • Major surgery (such as cardiopulmonary bypass)

    • Long-term fasting

    • Total parenteral nutrition

    • Sepsis arising from any infection (including pneumonia)

    • Diabetes mellitus – there is an increased risk of gallbladder disease in people with diabetes[20]

    • Atherosclerotic disease

    • Systemic vasculitis

    • Acute renal failure

    • HIV – cholangiopathy due to infection can occur.

Other diagnostic factors



Enquire about fever and chills. These may be present as a symptom of infection.

  • Persistent pain and fever may suggest either more complicated disease such as abscess formation or perforation, or acalculous cholecystitis.


Enquire about nausea. It can occur in conjunction with severe pain. It can be a prominent symptom of a stone in the common bile duct.

right shoulder pain

Ask about shoulder pain. Referred pain from the gallbladder may be felt in the right shoulder or interscapular region.


Ask about food and drink intake. Anorexia is associated with biliary disease. Not specific for cholecystitis.



Ask whether the patient has vomited. Sometimes associated with biliary disease. Not specific for cholecystitis. It can be a prominent symptom of a stone in the common bile duct.


Check for jaundice.[3]

  • Caused by inflammation and oedema around the biliary tract and direct pressure on the biliary tract from the distended gallbladder.[3]

  • Present in about 10% of patients with cholecystitis.[1]

Use of this content is subject to our disclaimer