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Emergency and acute medicine – acute cholecystitis
Definition and pathogenesis
Acute cholecystitis refers to inflammation of the gallbladder, most often resulting from obstruction of bile flow. The condition is usually precipitated by prolonged blockage of the gallbladder neck or cystic duct, leading to bile stasis, rising intraluminal pressure, mucosal injury, and subsequent inflammatory changes such as edema and increased vascularity.
Underlying causes
The most common form is acute calculous cholecystitis, caused by gallstone obstruction in the gallbladder neck, cystic duct, or occasionally the common bile duct. Secondary bacterial infection with coliforms and anaerobes may occur, although their primary role remains debated. Acalculous cholecystitis accounts for roughly 10% of cases and typically develops in critically ill patients due to biliary stasis and gallbladder ischemia, followed by inflammation and infection. In children, calculous cholecystitis is rare, whereas the acalculous form is more common and often associated with systemic infections such as sepsis, scarlet fever, Kawasaki disease, or parasitic illness.
Clinical features
Patients with calculous cholecystitis usually present with dull, aching epigastric or right upper quadrant pain that may radiate to the right scapula, shoulder, or thoracic spine. Pain persisting longer than six hours favors cholecystitis over uncomplicated biliary colic. As inflammation progresses, pain becomes sharper and more localized due to parietal peritoneal irritation. Nausea, vomiting, fever, and chills are common but not universal, and jaundice occurs in a minority of patients. A history of prior biliary colic or known gallstones supports the diagnosis. In contrast, acalculous cholecystitis often presents atypically in critically ill patients, with minimal localized abdominal pain and features of sepsis without an obvious source.
Physical examination findings
Localized right upper quadrant tenderness with percussion sensitivity or rebound may develop as inflammation advances. A positive Murphy sign—sudden inspiratory arrest during gentle palpation of the right upper quadrant—is present in most cases. In severe disease, signs of peritonitis or systemic toxicity may be evident.
Initial evaluation
Essential investigations include a complete blood count, liver function tests, amylase and lipase, urinalysis, and pregnancy testing when appropriate. Electrocardiography is recommended in patients at risk for coronary artery disease to exclude cardiac causes of pain. Imaging with right upper quadrant ultrasound is the preferred initial diagnostic test, with hepatobiliary scintigraphy reserved for equivocal cases or suspected acalculous cholecystitis.
Laboratory and imaging characteristics
Leukocytosis supports the diagnosis but may be absent in many patients. Liver enzymes and pancreatic markers are usually normal or only mildly elevated; disproportionate elevations in bilirubin or alkaline phosphatase raise concern for common bile duct obstruction or cholangitis. Ultrasound typically demonstrates gallbladder wall thickening, pericholecystic fluid, or gallstones and has high sensitivity and specificity. Hepatobiliary scintigraphy is highly sensitive and specific when ultrasound findings are inconclusive. CT imaging is useful to exclude complications such as perforation, emphysematous cholecystitis, or alternative intra-abdominal pathology.
Diagnostic considerations
Conditions that may mimic acute cholecystitis include biliary colic, cholangitis, hepatitis, hepatic abscess, pancreatitis, peptic ulcer disease, intestinal perforation, right lower lobe pneumonia, myocardial infarction, abdominal aortic aneurysm, appendicitis, and pyelonephritis.
Early management
Initial treatment focuses on supportive care, including intravenous access, fluid resuscitation for dehydration or sepsis, supplemental oxygen, and cardiac monitoring until myocardial ischemia is excluded. Patients should be kept nil per os, with nasogastric decompression if vomiting or ileus is present.
Emergency department therapy
Broad-spectrum intravenous antibiotics covering gram-negative coliforms, anaerobes, and Enterococcus species should be started promptly. Suitable regimens include beta-lactam/beta-lactamase inhibitor combinations, with aminoglycosides added if sepsis or cholangitis is suspected. Alternative regimens are required for patients with penicillin allergy. Antiemetics and opioid analgesics may be administered once the diagnosis is reasonably secure, with caution regarding sphincter of Oddi spasm. Early surgical consultation is mandatory.
Disposition and follow-up
All patients with acute cholecystitis require hospital admission for intravenous antibiotics, analgesia, fluid management, and definitive surgical treatment, typically cholecystectomy within 24–72 hours. Unstable patients or those with complications such as perforation or sepsis require urgent operative intervention. Discharge from the emergency department is not appropriate.
Clinical pearls
Ultrasound is the first-line imaging modality in suspected cholecystitis. Hepatobiliary scintigraphy should be obtained when ultrasound is inconclusive or acalculous cholecystitis is suspected. Early recognition, prompt antibiotics, and timely surgical involvement are essential to prevent complications.
Definition and pathogenesis
Acute cholecystitis refers to inflammation of the gallbladder, most often resulting from obstruction of bile flow. The condition is usually precipitated by prolonged blockage of the gallbladder neck or cystic duct, leading to bile stasis, rising intraluminal pressure, mucosal injury, and subsequent inflammatory changes such as edema and increased vascularity.
Underlying causes
The most common form is acute calculous cholecystitis, caused by gallstone obstruction in the gallbladder neck, cystic duct, or occasionally the common bile duct. Secondary bacterial infection with coliforms and anaerobes may occur, although their primary role remains debated. Acalculous cholecystitis accounts for roughly 10% of cases and typically develops in critically ill patients due to biliary stasis and gallbladder ischemia, followed by inflammation and infection. In children, calculous cholecystitis is rare, whereas the acalculous form is more common and often associated with systemic infections such as sepsis, scarlet fever, Kawasaki disease, or parasitic illness.
Clinical features
Patients with calculous cholecystitis usually present with dull, aching epigastric or right upper quadrant pain that may radiate to the right scapula, shoulder, or thoracic spine. Pain persisting longer than six hours favors cholecystitis over uncomplicated biliary colic. As inflammation progresses, pain becomes sharper and more localized due to parietal peritoneal irritation. Nausea, vomiting, fever, and chills are common but not universal, and jaundice occurs in a minority of patients. A history of prior biliary colic or known gallstones supports the diagnosis. In contrast, acalculous cholecystitis often presents atypically in critically ill patients, with minimal localized abdominal pain and features of sepsis without an obvious source.
Physical examination findings
Localized right upper quadrant tenderness with percussion sensitivity or rebound may develop as inflammation advances. A positive Murphy sign—sudden inspiratory arrest during gentle palpation of the right upper quadrant—is present in most cases. In severe disease, signs of peritonitis or systemic toxicity may be evident.
Initial evaluation
Essential investigations include a complete blood count, liver function tests, amylase and lipase, urinalysis, and pregnancy testing when appropriate. Electrocardiography is recommended in patients at risk for coronary artery disease to exclude cardiac causes of pain. Imaging with right upper quadrant ultrasound is the preferred initial diagnostic test, with hepatobiliary scintigraphy reserved for equivocal cases or suspected acalculous cholecystitis.
Laboratory and imaging characteristics
Leukocytosis supports the diagnosis but may be absent in many patients. Liver enzymes and pancreatic markers are usually normal or only mildly elevated; disproportionate elevations in bilirubin or alkaline phosphatase raise concern for common bile duct obstruction or cholangitis. Ultrasound typically demonstrates gallbladder wall thickening, pericholecystic fluid, or gallstones and has high sensitivity and specificity. Hepatobiliary scintigraphy is highly sensitive and specific when ultrasound findings are inconclusive. CT imaging is useful to exclude complications such as perforation, emphysematous cholecystitis, or alternative intra-abdominal pathology.
Diagnostic considerations
Conditions that may mimic acute cholecystitis include biliary colic, cholangitis, hepatitis, hepatic abscess, pancreatitis, peptic ulcer disease, intestinal perforation, right lower lobe pneumonia, myocardial infarction, abdominal aortic aneurysm, appendicitis, and pyelonephritis.
Early management
Initial treatment focuses on supportive care, including intravenous access, fluid resuscitation for dehydration or sepsis, supplemental oxygen, and cardiac monitoring until myocardial ischemia is excluded. Patients should be kept nil per os, with nasogastric decompression if vomiting or ileus is present.
Emergency department therapy
Broad-spectrum intravenous antibiotics covering gram-negative coliforms, anaerobes, and Enterococcus species should be started promptly. Suitable regimens include beta-lactam/beta-lactamase inhibitor combinations, with aminoglycosides added if sepsis or cholangitis is suspected. Alternative regimens are required for patients with penicillin allergy. Antiemetics and opioid analgesics may be administered once the diagnosis is reasonably secure, with caution regarding sphincter of Oddi spasm. Early surgical consultation is mandatory.
Disposition and follow-up
All patients with acute cholecystitis require hospital admission for intravenous antibiotics, analgesia, fluid management, and definitive surgical treatment, typically cholecystectomy within 24–72 hours. Unstable patients or those with complications such as perforation or sepsis require urgent operative intervention. Discharge from the emergency department is not appropriate.
Clinical pearls
Ultrasound is the first-line imaging modality in suspected cholecystitis. Hepatobiliary scintigraphy should be obtained when ultrasound is inconclusive or acalculous cholecystitis is suspected. Early recognition, prompt antibiotics, and timely surgical involvement are essential to prevent complications.
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