Cholecystitis

Acute cholecystitis is inflammation of the gallbladder, most commonly (90-95%) caused by gallstone obstruction of the cystic duct. It affects approximately 200,000 people in the US annually and develops in 1-3% of patients with symptomatic gallstones. [1-2]

Clinical Presentation

The typical presentation includes acute right upper quadrant pain, fever, and nausea that may be associated with eating. [1] Physical examination findings include right upper quadrant tenderness, with the Murphy sign being a specific finding for acute cholecystitis. [3]

Diagnosis

Ultrasonography is the initial imaging choice, with sensitivity of approximately 81% and specificity of approximately 83%. [1][3] Typical ultrasound findings include pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones, and a positive sonographic Murphy sign. [2]

When ultrasound results are negative or equivocal, hepatobiliary scintigraphy (HIDA scan) is the gold standard diagnostic test. [1][3]

Severity Classification

The Tokyo Guidelines classify acute cholecystitis into three grades (I-III) based on clinical presentation, laboratory values, imaging, and presence of organ dysfunction, which guides management. [4-5]

Management

Early laparoscopic cholecystectomy (within 1-3 days of diagnosis, up to 7-10 days from symptom onset) is the first-line therapy for most patients and is associated with: [1][7]

• Fewer composite postoperative complications (11.8% vs 34.4% for late surgery)
• Shorter hospital stay (5.4 vs 10.0 days)
• Lower hospital costs

Medical management before surgery includes: [5][7]

• Fasting and intravenous fluid resuscitation
• Antimicrobial therapy (second-generation cephalosporin or quinolone plus metronidazole) if infection is suspected (WBC >12,500/mm³ or temperature >38.5°C)
• Analgesics (NSAIDs such as diclofenac are safe and effective for pain control) [3][5]

Special Populations

• Pregnancy: Early laparoscopic cholecystectomy is safe during all trimesters and is associated with lower maternal-fetal complications (1.6% vs 18.4% for delayed management). [1][8]
• Elderly patients (>65 years): Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared with nonoperative management (29.3%). [1]
• High-risk surgical candidates: Percutaneous cholecystostomy tube placement can serve as bridge-to-surgery or definitive therapy, though it has higher postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). [1][4]

Acalculous Cholecystitis

Approximately 5-10% of acute cholecystitis cases are acalculous, typically occurring in critically ill patients with gallbladder-emptying dysfunction. [1][4] Percutaneous cholecystostomy should be reserved for severely ill patients; others should undergo laparoscopic cholecystectomy. [1]

Alternative Drainage Options

For patients unfit for surgery, options include: [9-10]

• Percutaneous transhepatic gallbladder drainage (PT-GBD) - most common, easy to perform
• Endoscopic transpapillary gallbladder drainage (ET-GBD) - for selected cases
• EUS-guided gallbladder drainage (EUS-GBD) - increasingly used with high technical success and lower reintervention rates

Conservative treatment with antibiotics alone should be regarded as a bridge to surgery rather than definitive therapy due to frequent recurrence (36% readmission rate). [11]

References

1. Acute Cholecystitis: A Review. — Gallaher JR, Charles A. The Journal of the American Medical Association. 2022.

2. The Management of Intra-Abdominal Infections From a Global Perspective: 2017 WSES Guidelines for Management of Intra-Abdominal Infections. — Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. World Journal of Emergency Surgery : WJES. 2017.

3. Gallstone Disease: Common Questions and Answers. — Patel H, Jepsen J. American Family Physician. 2024.

4. Indications for and Optimal Management of Percutaneous Cholecystectomy Drainage. — Sadaka AH, Tseng JF, Itani KMF. JAMA Surgery. 2025.

5. Acute Calculous Cholecystitis. — Strasberg SM. The New England Journal of Medicine. 2008.

6. Gallstones. — Piero Portincasa, David Q.‐H. Wang Yamada's Textbook of Gastroenterology 7e. 2022.

7. The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach. — Mencarini L, Vestito A, Zagari RM, Montagnani M. Journal of Clinical Medicine. 2024.

8. AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review. — Kothari S, Afshar Y, Friedman LS, Ahn J. Gastroenterology. 2024.

9. Acute Cholecystitis: Which Flow-Chart for the Most Appropriate Management?. — Kurihara H, Binda C, Cimino MM, et al. Digestive and Liver Disease : Official Journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2023.

10. AGA Clinical Practice Update on Role of EUS-Guided Gallbladder Drainage in Acute Cholecystitis: Commentary. — Irani SS, Sharzehi K, Siddiqui UD. Clinical Gastroenterology and Hepatology : The Official Clinical Practice Journal of the American Gastroenterological Association. 2023.

11. Retrospective Analysis of Non-Surgical Treatment of Acute Cholecystitis. — Janssen ERI, Hendriks T, Natroshvili T, Bremers AJA. Surgical Infections. 2020.