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 dev…
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]
![Management of acute cholecystitis. GB, gallbladder; Lap, laparoscopic; LC, laparoscopic cholecystectomy. Source: Miura et al. 2013 [321]. Reproduced with permission of the Journal of Hepato‐Biliary‐Pancreatic Sciences.](/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F7ec4dy8j%2Fproduction%2Ff051a7787c69ec79dea7b1df4ee7d7596d49b158-820x418.jpg&w=3840&q=75)
- 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.