Acute Cholecystitis
Summary
Acute Cholecystitis is the acute inflammation of the gallbladder, almost always (>90%) caused by the impaction of a gallstone in the Cystic Duct (Calculous Cholecystitis). The obstruction leads to bile stasis, chemical irritation, and subsequent bacterial superinfection. It is a surgical emergency necessitating antibiotics and, increasingly, early "hot" laparoscopic cholecystectomy. [1,2]
The Clinical Spectrum
- Biliary Colic: Temporary obstruction. Pain less than 6 hours. No inflammation (Normal WCC/CRP). Murphy's Negative.
- Acute Cholecystitis: Persistent obstruction. Pain >6 hours. Inflammation (High WCC/CRP). Murphy's Positive.
- Ascending Cholangitis: Obstruction of the Common Bile Duct. Jaundice + Fever + Rigors (Charcot's Triad). Sepsis.
Clinical Pearls
Murphy's Sign: The pathognomonic sign. Place hand in RUQ. Ask patient to inspire deeply. The inflamed gallbladder descends and hits your hand, causing a sharp catch in breath ("Inspiratory Arrest"). If they don't stop breathing, it's not Murphy's.
Boas' Sign: Hyperaesthesia or referred pain below the Right Scapula (T9 dermatome), mediated by the Phrenic nerve.
Jaundice Warning: Simple Cholecystitis should NOT cause jaundice. If the patient is yellow, the stone is either in the CBD (Choledocholithiasis) or compressing it externally (Mirizzi Syndrome).
Demographics
- Prevalence: 10-15% of adults have gallstones. Cholecystitis develops in 1-3% of symptomatic carriers annually.
- Risk Factors (The 5 Fs):
- Fat (Obesity).
- Female.
- Forty (typical age).
- Fertile (High oestrogen/Pregnancy).
- Fair (Caucasian).
Aetiology
- Calculous (90%): Gallstones.
- Acalculous (10%): Stasis/Ischemia in critically ill patients (ICU, Burns, Trauma). High mortality.
Sequence of Events
- Obstruction: Stone impacts the Cystic Duct or Hartmann's Pouch.
- Distension: Mucus secretion continues, distending the gallbladder (Hydrops).
- Ischaemia: Intraluminal pressure exceeds venous perfusion pressure.
- Inflammation: Chemical irritation of mucosa by Lysolecithin (from bile salts).
- Infection: Bacterial colonisation (E. Coli, Klebsiella, Enterococcus) occurs in 50-75%.
Symptoms
Signs
- Abdomen: RUQ tenderness and guarding. Palpable mass (Omentum wrapping around GB) in 20%.
- General: dehydrated, Tachycardic.
Bedside
- Urinalysis: Exclude Pyelonephritis.
- ECG: Exclude Inferior MI.
Bloods
- FBC / CRP: Elevated WCC (Neutrophilia) and CRP. Essential to distinguish from colic.
- LFTs: Usually Normal. Mild ALT/ALP elevation possible due to reactive hepatitis. High Bilirubin implies CBD pathology.
- Amylase: Check to exclude pancreatitis.
Imaging (Tokyo Guidelines)
- Ultrasound (Gold Standard):
- Wall thickening (>3mm).
- Pericholecystic Fluid.
- Sonographic Murphy's Sign (Tenderness when probe pushes GB).
- Stones/Sludge.
- CT Abdomen: Use if diagnosis unclear or complications (perforation) suspected.
- HIDA Scan: High sensitivity (shows non-filling of GB) but rarely used acutely.
Management Algorithm
ACUTE CHOLECYSTITIS
(Pain, Murphy's+, High CRP)
↓
ADMIT & RESUSCITATE (Sepsis 6)
- IV Fluids
- IV Antibiotics (Co-amoxiclav)
- Analgesia (Morphine)
- Keep NBM
↓
ASSESS OPERATIVE FITNESS
┌─────────┴─────────┐
FIT UNFIT
↓ ↓
TIMING OF ONSET? CHOLECYSTOSTOMY
│ (Percutaneous Drain)
├─ less than 1 Week ─────┐
↓ ↓
EARLY SURGERY DELAYED SURGERY
"Hot Lap Chole" (6-8 weeks later)
(less than 72 hours) "Interval Chole"
Surgical Management (Laparoscopic Cholecystectomy)
- Early ("Hot"): Surgery within 7 days (ideally 72h) of onset. Preferred strategy. Reduces hospital stay and readmission.
- Delayed ("Interval"): If presentation is late (>1 week), inflammation makes dissection dangerous ("frozen Calot's triangle"). Treat with antibiotics and operate in 6-8 weeks.
Non-Surgical
- Conservative: Antibiotics alone. (High recurrence rate).
- Percutaneous Cholecystostomy: Radiologist inserts a pigtail drain through the liver into the gallbladder. Used for septic patients unfit for anaesthesia ("Damage Control").
- Empyema: Gallbladder fills with pus. Toxic.
- Gangrenous Cholecystitis: Ischaemic wall necrosis.
- Perforation:
- Localised: Pericholecystic abscess.
- Free: Biliary peritonitis (High mortality).
- Mirizzi Syndrome: Large stone in Cystic Duct compresses the Common Hepatic Duct.
- Gallstone Ileus: Fistula between GB and Duodenum -> Stone enters small bowel -> Blocks Terminal Ileum (Rigler's Triad on AXR).
- Mortality: Low (less than 0.5%) for elective/early lap chole. Higher in elderly/emergency.
- Post-Cholecystectomy Syndrome: 10% have ongoing vague pain/diarrhoea post-op.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| TG18 (Tokyo) | JSHBPS | Diagnostic criteria and severity grading (Grade I-III). |
| Gallstones | NICE CG188 | Offer early laparoscopic cholecystectomy within 1 week of diagnosis. |
Landmark Evidence
1. ACDC Study (2013)
- Randomized Acute vs Delayed Cholecystectomy.
- Found early surgery reduced morbidity and hospital costs vs delayed.
What is Cholecystitis?
It is an infection of the gallbladder (a small sac under the liver) caused by a gallstone getting stuck in the tube leading out of it. It's like a blockage causing pressure and swelling.
Can I pass the stone?
No. Once the gallbladder is inflamed, the swelling traps the stone. Even if it did pass, you have a bag full of other stones waiting to cause the same problem.
What is the treatment?
We recommend removing the gallbladder ("Keyhole surgery") while you are in hospital. This removes the source of infection and stops it ever happening again.
Can I live without a gallbladder?
Yes. The gallbladder just stores bile. Your liver will still make bile, but it will drip continuously into your gut. You digest food normally.
Primary Sources
- Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018.
- NICE. Gallstones disease: diagnosis and management [CG188]. 2014.
- Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013.
Common Exam Questions
- Sign: "Inspiratory arrest in RUQ?"
- Answer: Murphy's Sign.
- Diagnosis: "Air in biliary tree + Small bowel obstruction?"
- Answer: Gallstone Ileus (Rigler's Triad).
- Management: "Best timing for surgery?"
- Answer: Within 72 hours / 1 week of onset ("Hot").
- Complication: "Jaundice in acute cholecystitis?"
- Answer: Mirizzi Syndrome or CBD stone.
Viva Points
- Charcot's Triad: Fever + Jaundice + RUQ Pain = Ascending Cholangitis (Emergency, needs ERCP).
- Reynolds' Pentad: Charcot's + Hypotension + Confusion = Toxic Shock in Cholangitis.
- Critical View of Safety: The surgical view required before clipping the cystic duct to avoid cutting the Common Bile Duct.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.