Acute cholecystitis
Acute cholecystitis is acute inflammation of the gallbladder, most commonly caused by impaction of a gallstone at the cystic duct or gallbladder neck. Obstruction causes bile stasis, mucosal injury and chemical inflammation; secondary bacterial infection (commonly Escherichia coli and Klebsiella spp.) may follow. Untreated disease can progress to empyema, gangrene, perforation and biliary sepsis.
This section summarises pathophysiology, typical presentation, investigation, emergency management and definitive treatment priorities, with emphasis on early operative timing and options for patients unfit for surgery (NICE CG188, QS104, HTG683).
Pathophysiology and complications
- Stone obstruction causes impaired gallbladder emptying, raised intraluminal pressure, mucosal ischaemia and inflammation.
- Secondary bacterial infection and pus (empyema) may develop following obstruction and inflammation.
- Severe inflammation increases the risk of gangrene and perforation of the gallbladder.
- Inflamed tissues make early surgery technically more demanding, but early definitive management improves outcomes for patients who are fit for surgery.
Clinical features
Typical presentation
- Pain is typically constant and severe in the right upper quadrant (RUQ) or epigastrium and often radiates to the back or right shoulder.
- Pain in acute cholecystitis usually persists beyond 12 hours, in contrast to biliary colic which resolves within hours.
- Systemic features such as fever, rigors, nausea and vomiting are common.