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Acute Cholecystitis

Clinical Subject Page

Acute Cholecystitis

Acute cholecystitis is acute inflammation of the gallbladder, most commonly caused by obstruction
of the cystic duct by a gallstone (acute calculous cholecystitis). Acalculous cholecystitis occurs
mainly in critically ill patients.

Also called

Acute Gallbladder Inflammation

ICD-10

K81.0

Specialty

Gastroenterology

Onset

Acute

Reviewed

July 2026

On This Page

Overview

• Usually results from gallstone obstruction of the cystic duct.
• Characterized by persistent right upper quadrant (RUQ) pain, Murphy sign, and systemic
inflammation.
• RUQ ultrasound is the preferred initial imaging modality.
• Main treatment includes supportive care, empiric antibiotics, and early laparoscopic
cholecystectomy.

Etiology & Risk Factors

-Causes:
• Acute calculous cholecystitis (most common): Cystic duct obstruction by a gallstone.


• Acute acalculous cholecystitis: Typically occurs in critically ill patients.


Risk Factors
• Gallstones
• Critical illness (for acalculous cholecystitis)

Pathophysiology

• Obstruction of the cystic duct leads to gallbladder distension.
• Inflammation and edema develop within the gallbladder wall.
• Secondary bacterial infection may occur.
• Untreated disease may progress to gangrene, perforation, or abscess formation.

Clinical Presentation

• Persistent right upper quadrant pain
• Fever
• Nausea
• Vomiting
• Positive Murphy sign

History Taking

-Ask about:
• Onset and duration of RUQ pain
• Pain severity
• Fever
• Nausea and vomiting
• Previous gallstone attacks
• Jaundice
• History of gallstones
• Previous biliary surgery

Physical Examination

• General assessment (ABCDE)
• Vital signs
• Right upper quadrant tenderness
• Murphy sign
• Assess for jaundice
• Evaluate for signs of sepsis or shock

Investigations

Initial laboratory studies
• Complete blood count (CBC)
• Basic metabolic panel (BMP)
• C-reactive protein (CRP)
• Coagulation studies


-Liver chemistries
• Lipase
• Amylase


-Blood cultures (2 sets) before antibiotics if infection is suspected


Imaging
Preferred initial imaging
• Right upper quadrant (RUQ) ultrasound
• Consider biliary point-of-care ultrasound (POCUS) if available.


Typical ultrasound findings:
• Gallbladder distension
• Gallbladder wall edema/thickening
• Pericholecystic fluid
Additional imaging (if ultrasound is inconclusive)
• CT abdomen
• MRI abdomen
• MRCP


-HIDA scan:
Evaluate for
• Choledocholithiasis
• Severity of acute cholecystitis

Diagnosis

-Diagnosis is based on:


1) Local signs of inflammation
• Murphy sign
• RUQ pain/tenderness


2) Systemic signs of inflammation
• Fever
• Leukocytosis
• Elevated CRP


3) Imaging
• Characteristic evidence of gallbladder inflammation on imaging

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Management

-Initial management
• Admit to hospital (all patients require inpatient management)
• Establish IV access
• Hemodynamic support
• Nil by mouth (NPO)
• IV fluids
• Analgesia
• Antiemetics
• Consider NG tube for intractable vomiting


-Antibiotics
• Start empiric antibiotic therapy for acute biliary infection promptly.


-Surgical management
Definitive treatment
• Early laparoscopic cholecystectomy
• Preferably performed within 72 hours of admission


-High-risk surgical patients
• Gallbladder drainage (e.g., percutaneous cholecystostomy or endoscopic gallbladder
stenting)
• Elective interval cholecystectomy after recovery


Consultations
• General surgery consultation is recommended for all patients

Complications

• Gangrenous cholecystitis
• Emphysematous cholecystitis
• Gallbladder perforation
• Biliary-enteric fistula
• Gallstone ileus
• Pyogenic liver abscess
• Chronic cholecystitis
• Increased risk of gallbladder carcinoma

Prognosis

• Excellent with early diagnosis and treatment.
• Delayed management increases the risk of complications.
• Early laparoscopic cholecystectomy reduces recurrence and improves outcomes.

Key Points / Clinical Pearls

• Acute cholecystitis is usually caused by cystic duct obstruction from a gallstone.
• Classic features: RUQ pain, Murphy sign, and fever.
• RUQ ultrasound is the investigation of choice.
• Initial labs: CBC, BMP, CRP, liver chemistries, amylase, lipase, coagulation studies, and
blood cultures.
• Diagnosis requires local signs of inflammation + systemic inflammation + imaging findings.
• Management includes NPO, IV fluids, analgesia, empiric antibiotics, and early laparoscopic
cholecystectomy.
• High-risk patients may require percutaneous cholecystostomy before definitive surgery