Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder, in most cases caused by a gallstone obstructing its outlet. It is distinct from biliary colic: colic is transient obstruction producing pain that resolves, whereas cholecystitis is sustained obstruction producing an inflammatory illness that does not settle on its own. It is one of the commonest emergency surgical admissions.
How it forms
A stone becomes impacted in the neck of the gallbladder or the cystic duct and stays there. The gallbladder continues to secrete mucus and cannot empty, so pressure rises within a closed space. Raised pressure compromises the blood supply in the wall, the mucosa is injured, and concentrated bile salts and phospholipids — irritant when in prolonged contact with damaged lining — drive a chemical inflammation.
Bacterial infection follows as a secondary event rather than initiating the process, which is why cholecystitis is not primarily an infective illness even though antibiotics form part of treatment.
If obstruction persists the inflammation progresses. The wall becomes oedematous and thickened, then in more severe cases the compromised blood supply leads to gangrene, and eventually perforation — either free into the abdomen, or contained by adherent omentum and bowel as a localised abscess. The time course matters clinically: the inflammatory process becomes progressively more fibrotic and adherent after several days, which is why the ease and safety of surgery changes with timing.
Acalculous cholecystitis occurs without stones, typically in critically ill patients — after major surgery, trauma, burns, sepsis or prolonged intensive care. The mechanism is bile stasis and impaired gallbladder perfusion rather than obstruction. It is easily missed in a sedated patient and carries a higher rate of gangrene and perforation.
Symptoms
- right upper abdominal pain, constant and lasting more than several hours — the key distinction from colic
- tenderness over the gallbladder, with Murphy's sign: arrest of inspiration on palpation
- fever
- nausea, vomiting and anorexia
- pain on movement, in contrast to the restlessness of colic
Jaundice is not typical and, when present, raises the possibility of a duct stone, Mirizzi syndrome (a stone in the gallbladder neck compressing the common hepatic duct), or cholangitis.
How the diagnosis is made
Diagnosis rests on the combination of local signs, systemic inflammation, and imaging — the framework set out in the Tokyo Guidelines, which also grade severity and guide management.
Blood tests show raised white cell count and CRP. Liver function tests are usually normal or mildly deranged; significant derangement suggests duct involvement.
Ultrasound demonstrates gallstones, a thickened gallbladder wall, pericholecystic fluid, and a sonographic Murphy's sign. CT is useful where complications such as perforation, abscess or emphysematous change are suspected, and in patients whose presentation is unclear. HIDA scintigraphy is highly accurate where doubt persists, showing failure of the gallbladder to fill.
Severity grading — mild, moderate or severe according to local findings and organ dysfunction — directly determines whether early surgery, delayed surgery or drainage is appropriate.
Treatment
Initial management
Admission, intravenous fluids, analgesia, withholding oral intake initially, and intravenous antibiotics covering the usual biliary organisms.
Early laparoscopic cholecystectomy
For mild and moderate disease in a patient fit for surgery, cholecystectomy during the same admission and ideally within the first seven days of symptoms is the preferred approach. Early surgery shortens total hospital stay, avoids the risk of further attacks while waiting, and — contrary to older teaching — does not increase complications when performed within that window.
The operation is technically more demanding than elective cholecystectomy because of oedema, adhesions and distorted anatomy. Where the anatomy cannot be defined safely, sound alternatives exist and should be used rather than persisting: conversion to open operation, or subtotal cholecystectomy, in which the gallbladder is opened, stones removed and the diseased portion excised while the part adherent to the liver and duct is left. Subtotal cholecystectomy is a legitimate and deliberate operation to avoid bile duct injury, not a failure.
Percutaneous cholecystostomy
Drainage of the gallbladder with a catheter under imaging guidance, used for patients too unwell or unfit for surgery. It controls sepsis, allowing recovery and, in suitable patients, cholecystectomy later. Some frail patients are managed with the drain alone.
Delayed surgery
Where presentation is late — beyond a week or so — or where the patient is unsuitable for immediate operation, the inflammation is settled with antibiotics and surgery performed after an interval of around six weeks, once the tissues have recovered. The disadvantage is the risk of further attacks in the interval, which is not negligible.
Complications if untreated
Gangrenous cholecystitis, perforation with localised abscess or generalised peritonitis, emphysematous cholecystitis (gas-forming infection, seen more often in diabetic patients), cholecystoenteric fistula and gallstone ileus, and Mirizzi syndrome. These are the reason cholecystitis is treated as an acute illness rather than observed.
Recovery
After early laparoscopic cholecystectomy, hospital stay is typically one to three days — longer than an elective operation — with return to normal activity in two to four weeks. After percutaneous drainage, the tube remains for a period and the patient is reassessed for later surgery.
Follow-up
Postoperative review confirms recovery and discusses the histology, since incidental gallbladder cancer is occasionally found in a gallbladder removed for inflammation. Patients managed without surgery are followed to plan definitive treatment.
When to seek medical attention
Right upper abdominal pain persisting beyond a few hours, particularly with fever, requires assessment the same day rather than a routine appointment. Patients known to have gallstones should be told this explicitly, since the distinction between an attack of colic that will settle and cholecystitis that will not is one of timing, and waiting at home is how a straightforward operation becomes a difficult one.
Common questions
What is the difference between biliary colic and cholecystitis?
Both are caused by a gallstone blocking the gallbladder outlet. In biliary colic the stone falls back, the blockage relieves itself, and the pain settles completely within a few hours. In cholecystitis the stone stays stuck, the gallbladder becomes inflamed and infected, and the pain does not go away. Pain lasting more than about six hours, especially with fever, suggests cholecystitis.
Is acute cholecystitis an emergency?
Yes. It needs hospital assessment the same day. It does not resolve on its own, and delay allows the gallbladder to become gangrenous or perforate.
Will I need an operation straight away?
Usually surgery during the same hospital admission, ideally within the first week of symptoms, gives the best results. Patients who are unfit for immediate surgery, or who present late, may instead be treated with antibiotics and have the operation after an interval, or have a drain placed into the gallbladder first.
Why is surgery harder for cholecystitis than for ordinary gallstones?
Inflammation makes the tissues swollen, fragile and stuck together, which obscures the anatomy. This is why the operation takes longer, why conversion to open surgery is more likely, and why it is sometimes safer to remove only part of the gallbladder rather than risk injuring the bile duct.
Can antibiotics alone cure it?
Antibiotics settle the inflammation in many patients, but the gallstones remain and attacks usually recur. Antibiotics are best understood as controlling the episode rather than treating the cause.
Can you get cholecystitis without gallstones?
Yes, though it is uncommon. Acalculous cholecystitis occurs mainly in people who are already seriously ill in hospital, and it can be more dangerous because it is harder to spot.
Related conditions
Other conditions of the gallbladder & bile ducts covered on this site:
- Gallstones and biliary colic
- Common bile duct stones and cholangitis
- Gallbladder polyps
- Obstructive jaundice
- Gallbladder cancer
- Cholangiocarcinoma (bile duct cancer)
- Bile duct strictures, cysts and benign tumours
- Bile duct injury after gallbladder surgery
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and investigations.