Acute Cholecystitis

What happens in acute cholecystitis

The gallbladder is a small pouch under the liver that stores bile and squeezes it into the intestine after meals. In about 90% to 95% of cases, a gallstone becomes stuck in the cystic duct, the gallbladder's outlet. Bile is trapped, pressure rises, and the gallbladder wall becomes inflamed and swollen. Bacterial infection often follows. Without treatment, the wall can lose its blood supply (gangrene), fill with pus (empyema) or burst.

Acalculous cholecystitis, without stones, occurs in very ill people: after major surgery, severe burns, trauma, sepsis or in intensive care. It is more dangerous because it is harder to recognize.

Acute cholecystitis vs biliary colic

See gallstones and biliary colic.

Symptoms

• severe, constant pain in the upper right or upper middle belly
• pain spreading to the right shoulder or between the shoulder blades
• pain often starting after a large or fatty meal
• nausea and vomiting
• fever and chills
• tenderness under the right ribs; taking a deep breath while a doctor presses there causes a sharp catch of pain (Murphy's sign)
• mild yellowing of the skin in some people

Older adults and people with diabetes may have little pain or fever despite significant inflammation.

Causes and risk factors

Gallstone risk factors (sometimes summarized as the "4 Fs": female, fertile, forty, fat) include:

• female sex, pregnancy and estrogen therapy
• age over 40
• obesity, and rapid weight loss including after bariatric surgery
• family history and some ethnic groups (such as Indigenous peoples of the Americas)
• diabetes
• cirrhosis and some blood disorders such as sickle cell disease (pigment stones)

Diagnosis

Doctors use clinical signs, blood tests and imaging together (as in the Tokyo Guidelines):

1. Examination: right upper belly tenderness, Murphy's sign, fever.
2. Blood tests: white blood cell count and CRP; liver tests, bilirubin and lipase to check for duct stones or pancreatitis.
3. Abdominal ultrasound: the first-choice test. It shows stones, a thickened gallbladder wall, fluid around the gallbladder, and tenderness when the probe presses on it (sonographic Murphy's sign).
4. HIDA scan: a nuclear scan that shows whether bile can enter the gallbladder; used when ultrasound is unclear.
5. CT or MRCP: for complications, or when a stone may be in the common bile duct.

Treatment

In hospital

• nothing by mouth at first, with intravenous fluids
• pain relief and anti-nausea medicines
• intravenous antibiotics covering gut bacteria

Gallbladder removal

Laparoscopic cholecystectomy (keyhole removal of the gallbladder) is the definitive treatment. Guidelines favor early surgery, ideally within 72 hours of symptom onset and generally within a week, during the same admission. Early surgery shortens total hospital time and prevents repeat attacks, which happen frequently if surgery is delayed.

If a stone has moved into the common bile duct, an ERCP (an endoscopic procedure) or bile duct exploration during surgery removes it.

When surgery is too risky

For people too unwell or frail for surgery, a radiologist can place a drainage tube through the skin into the gallbladder (percutaneous cholecystostomy). Endoscopic drainage is another option at specialist centers. Surgery may follow once they recover.

Life without a gallbladder

You do not need a gallbladder to digest food normally. Bile flows directly from the liver to the intestine. Some people have looser stools for a few weeks or months after surgery; this usually settles.

Complications

• Gangrenous cholecystitis: dead gallbladder wall
• Empyema: gallbladder filled with pus
• Perforation, causing an abscess or peritonitis
• Emphysematous cholecystitis: gas-forming infection, more common in men with diabetes
• Cholangitis and pancreatitis if a stone moves into the bile duct
• Gallstone ileus: a large stone erodes into the bowel and blocks it (rare)
• Sepsis

Recovery and outlook

After laparoscopic surgery, most people go home within 1 to 2 days and return to normal activities in 1 to 2 weeks. Serious complications of surgery, such as bile duct injury or bile leak, are uncommon. Mortality from uncomplicated acute cholecystitis is low, but it rises with age, acalculous disease and complications.

Prevention

• keep to a healthy weight and avoid crash diets; lose weight gradually
• regular physical activity
• a diet rich in fiber and lower in refined carbohydrates
• if you have had biliary colic, discuss planned gallbladder removal with your doctor

Frequently asked questions

What are the symptoms of acute cholecystitis?

The main symptom is constant, severe pain in the upper right belly lasting more than 6 hours, often spreading to the right shoulder. Fever, nausea, vomiting and tenderness under the right ribs are common. Some people develop mild yellowing of the skin.

How is acute cholecystitis different from a gallbladder attack?

A gallbladder attack (biliary colic) is pain from a stone briefly blocking the duct and usually settles within a few hours. In acute cholecystitis, the blockage persists and the gallbladder becomes inflamed or infected, causing longer pain, fever and tenderness that need hospital treatment.

Does acute cholecystitis always need surgery?

Most people are advised to have their gallbladder removed, ideally during the same hospital stay, because attacks often recur. People who are too unwell for surgery can have the gallbladder drained through the skin and may have surgery later or not at all.

Can acute cholecystitis go away on its own?

Inflammation can sometimes settle with antibiotics and rest, but the gallstones remain and the risk of another attack or complications is high. Untreated acute cholecystitis can lead to gangrene, perforation or sepsis, so it always needs medical care.

What can I eat after acute cholecystitis?

After gallbladder removal, most people can eat normally. Start with smaller, lower-fat meals for the first few weeks and add foods back gradually. If surgery is delayed, a low-fat diet may reduce attacks while you wait.