Acute cholecystitis is a major complication of cholelithiasis (i.e., gallstones); symptomatic gallstones are common before developing cholecystitis.
Right upper quadrant (RUQ) pain lasting more than 3 to 6 hours and fever are common.
RUQ tenderness, a distended RUQ mass, and positive Murphy sign are key examination findings.
Ultrasound is the initial test of choice; hepatobiliary iminodiacetic acid (HIDA) scanning and magnetic resonance imaging may be helpful in cases where diagnosis is unclear.
Treatment is early cholecystectomy.
Acute cholecystitis is acute inflammation of the gallbladder, and is one of the major complications of cholelithiasis (the presence of gallstones). In most cases (90%), acute cholecystitis is caused by obstruction of the cystic duct due to a stone 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 acalculous cholecystitis.
Bacterial infection can develop as a secondary feature; it is not an initiating event. Infection may be community- or healthcare-acquired. This topic covers community-acquired infection only.
History and exam
Key diagnostic factors
- previous episode of biliary pain
- right upper quadrant pain
- positive Murphy sign
- abdominal mass
Other diagnostic factors
- right shoulder pain
- physical inactivity
- low fiber intake
- severe illness
- severe burns
- total parenteral nutrition (TPN)
- hepatic arterial embolization
1st investigations to order
- C-reactive protein
- right upper quadrant ultrasound scan
Investigations to consider
- cholescintigraphy (hepatobiliary iminodiacetic acid [HIDA] scan)
- abdominal CT
- abdominal MRI
- abdominal x-ray
mild (grade I): stable without signs of perforation/gangrene
moderate (grade II): stable with signs of perforation/gangrene
severe (grade III): suspected gangrene/perforation or evidence of organ dysfunction
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- Chronic cholecystitis
- Peptic ulcer disease
- ACR Appropriateness Criteria: right upper quadrant pain
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