24th July 2023

Acute cholecystitis

Acute inflammation of the gallbladder, which most commonly occurs as a complication of gallstones. Rare causes include chemotherapy and vasculitis.

Clinical features

Presents with acute right upper quadrant pain, which is typically more severe and more constant than the biliary colic of gallstones. Often associated with nausea, vomiting, and unlike gallstones is more likely to be associated with systemic upset, such as fever and rigors. Jaundice is not commonly associated.

A positive Murphy’s sign is a characteristic examination finding (severe pain on palpation of right upper quadrant during inspiration) and indicates inflammation of the gallbladder.

Assessment and diagnosis

Ultrasound is the diagnostic test of choice. Typical findings include pericholecystic fluid (fluid around the gallbladder), a distended gallbladder, oedematous gallbladder wall, and gallstones). Blood tests may be normal or show mild elevation of WCC, CRP, bilirubin and AST/ALT.

Management

Immediate management includes analgesia and IV fluids. Many patients will settle with conservative treatment, and cholecystectomy should be subsequently planned electively as definitive management.

If there are signs of superimposed infection, then broad spectrum IV antibiotics (i.e. cefuroxime and metronidazole) should be given.

Emergency cholecystectomy may be indicated if there are complications, such as generalised peritonitis (suggesting perforation), or gangrene of the gallbladder. If surgery needs to be done acutely, then a laparoscopic method is preferred due to lower complication rates – elective surgery tends to be open.