Acute Cholecystitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Acute cholecystitis is inflammation of the gallbladder, usually caused by gallstones obstructing the cystic duct, leading to infection and inflammation.

Aetiology

  • Calculous cholecystitis (90% of cases): gallstones obstruct the cystic duct, leading to gallbladder inflammation.
  • Acalculous cholecystitis: inflammation without gallstones, often in critically ill patients.
  • Bacterial infection: secondary infection by Escherichia coli, Klebsiella, or Enterococcus.

Pathophysiology

  • Gallstone obstruction leads to bile stasis, causing irritation and inflammation of the gallbladder wall.
  • Infection may develop, leading to purulent fluid collection (empyema).
  • Severe cases can result in perforation or gangrenous cholecystitis.

Risk factors

  • Female gender (higher prevalence due to oestrogen effects).
  • Age >40 years.
  • Obesity or rapid weight loss.
  • High-fat diet.
  • Diabetes mellitus.
  • Pregnancy (increased gallstone formation).

Signs and symptoms

Symptoms:

  • Severe right upper quadrant (RUQ) pain, often radiating to the right shoulder.
  • Pain worsens after fatty meals.
  • Fever and chills.
  • Nausea and vomiting.

Signs:

  • Murphy’s sign: Pain on deep inspiration when palpating the RUQ.
  • RUQ tenderness.
  • Tachycardia and fever (suggesting systemic involvement).

Investigations

  • Blood tests:
    • Raised white cell count (WCC) and C-reactive protein (CRP) (indicating infection).
    • Liver function tests (LFTs): May show elevated ALP and bilirubin if bile duct obstruction is present.
  • Imaging:
    • Ultrasound (first-line): may show gallstones, thickened gallbladder wall (>3mm), and fluid around the gallbladder.
    • CT scan: used if complications like perforation are suspected.
    • HIDA scan: functional imaging for unclear cases, showing cystic duct obstruction.

Management

1. Initial Stabilisation:

  • Nil by mouth: to reduce gallbladder stimulation.
  • IV fluids: to maintain hydration.
  • IV antibiotics: broad-spectrum antibiotics (e.g., co-amoxiclav or ceftriaxone + metronidazole).
  • Pain management: NSAIDs or opioids (avoid morphine due to sphincter of Oddi spasm).

2. Surgical Management:

  • Early laparoscopic cholecystectomy (gold standard): performed within 48–72 hours to prevent recurrence.
  • Delayed cholecystectomy: for those initially managed conservatively, performed after inflammation subsides.

3. Conservative Management (for high-risk patients):

  • Antibiotic therapy with close monitoring.
  • Percutaneous cholecystostomy (drainage) if surgery is not an option.

Referral

  • Emergency surgical referral: for all suspected cases requiring cholecystectomy.
  • Gastroenterology referral: if choledocholithiasis (common bile duct stones) is suspected.
  • Intensive care referral: if sepsis or shock develops.
GastroenterologymypanotesAcute Cholecystitis