Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
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What this article covers
- Overview
Definition: acute cholecystitis is inflammation of the gallbladder, most often triggered by obstruction of the cystic duct, with resulting bile stasis, distention, and frequently secondary bacterial infection.
- Epidemiology
Dominant cause: cystic duct obstruction by a gallstone, arising in patients with underlying gallstone disease.
- Risk factors
Gallstone disease: the dominant risk factor for calculous cholecystitis, since an impacted cystic duct stone is the usual trigger.
- Pathophysiology
Obstruction is the initiating event: a gallstone lodges in the cystic duct, blocking gallbladder outflow and producing bile stasis and rising intraluminal pressure.
- Clinical features
Murphy sign: inspiratory arrest during deep palpation of the RUQ from pain, the hallmark examination finding.
- Differential diagnosis
Acute cholangitis: fever, RUQ pain, and jaundice (Charcot triad) with a marked cholestatic liver-chemistry rise, reflecting common bile duct rather than cystic duct obstruction (acute cholangitis).
- Diagnosis
Establish with the Tokyo Guidelines (TG18) criteria across three domains, then classify certainty: a suspected diagnosis requires one item from A plus one item from B, and a definite diagnosis requires one item from each of A, B, and C.
- Management
Give analgesia and start empiric IV antibiotics with gram-negative and anaerobic coverage as soon as the diagnosis is suspected, while imaging and surgical evaluation proceed.
- Complications
Gallbladder perforation: the most feared complication, presenting with worsening pain and peritoneal signs, and requiring emergency surgery.
- Prognosis
Outlook is generally favorable with timely surgery: most patients recover fully after early laparoscopic cholecystectomy, particularly with Grade I or II disease.
- Prevention
Cholecystectomy for symptomatic gallstones: patients with typical biliary colic symptoms and gallstones on imaging should undergo cholecystectomy before an episode of cholecystitis develops.
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