FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Pancreatobiliary

Acute cholecystitis

Inflammation of the gallbladder (cystic-duct obstruction by a stone; rarely acalculous)

Overview

Inflammation of the gallbladder, usually from sustained cystic-duct obstruction by a stone (acalculous in the critically ill). Unlike biliary colic, there is INFLAMMATION: persistent RUQ pain, fever and a positive Murphy sign with raised inflammatory markers but NORMAL LFTs (the duct is the cystic, not the common bile duct). Treated with antibiotics, analgesia and early laparoscopic cholecystectomy (within ~1 week).

Recognise

  • Persistent (>6 h) RUQ pain radiating to the shoulder, FEVER, nausea/vomiting; MURPHY sign positive (arrest of inspiration on RUQ palpation)
  • Raised WCC/CRP; LFTs usually NORMAL (cystic-duct, not CBD, obstruction); ultrasound: thick-walled gallbladder, stones, pericholecystic fluid, sonographic Murphy
  • Complications: empyema, gangrene/perforation, gallbladder fistula → gallstone ileus

Red flags

  • Sepsis, gangrene/perforation, empyema → urgent surgery
  • Jaundice + deranged LFTs → coexisting CBD stone/cholangitis (Mirizzi syndrome)

Differentials & how to tell them apart

Biliary colicepisodic pain, NO fever, normal inflammatory markers — no inflammation
Acute cholangitisCharcot triad (+ jaundice + abnormal LFTs) — CBD stone + infection
Peptic ulcer/perforation, pancreatitis, hepatitisepigastric pain patterns/amylase/LFTs
Right basal pneumoniareferred RUQ pain — examine the chest

Investigations

ULTRASOUND (thick-walled gallbladder >3 mm, stones, pericholecystic fluid, sonographic Murphy); FBC/CRP (raised), LFTs (usually normal — abnormal suggests CBD involvement); amylase (exclude pancreatitis).

Management

IV antibiotics + analgesia + early laparoscopic cholecystectomy (within ~1 week)

  1. 1Resuscitate, IV antibiotics and analgesia. Confirm with ultrasound. Refer for EARLY laparoscopic cholecystectomy (within ~1 week of presentation).Gate: NORMAL LFTs point to cystic-duct cholecystitis; ABNORMAL LFTs/jaundice mean a coexisting CBD stone or cholangitis (needs MRCP/ERCP) — don't miss the duct stone; acalculous cholecystitis occurs in the critically ill
  2. 2Early cholecystectomy; percutaneous cholecystostomy if unfit for surgery; ERCP for CBD stones; manage complications (empyema/perforation).
IV antibiotics + analgesia + fluids — e.g. co-amoxiclav; nil by mouth, resuscitate
Early laparoscopic cholecystectomy (within ~1 week) — definitive — NICE recommends early surgery

Key points

Persistent RUQ pain + fever + Murphy sign + raised inflammatory markers but NORMAL LFTs = acute cholecystitis → antibiotics + early lap chole. Abnormal LFTs/jaundice means the stone is in the CBD (cholangitis/Mirizzi).

Monitor & prognosis

Sepsis/response; LFTs (CBD involvement).

Good with early surgery.

Source: NICE CG188; Tokyo guidelines