Acute Cholecystitis

Acute cholecystitis refers to inflammation of the gallbladder, which is caused by a blockage of the cystic duct preventing the gallbladder from draining. It is a key complication of gallstones, and the majority of cases (around 95%) are caused by gallstones (calculous cholecystitis). Gallstones may be trapped in the neck of the gallbladder or in the cystic duct. 

In a small number of cases, the dysfunction in gallbladder emptying is caused by something other than gallstones (acalculous cholecystitis). One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

 

Presentation

The main presenting symptom of cholecystitis is pain in the right upper quadrant (RUQ). This may radiate to the right shoulder.

Other features include:

  • Fever
  • Nausea
  • Vomiting
  • Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
  • Right upper quadrant tenderness
  • Murphy’s sign
  • Raised inflammatory markers and white blood cells

 

Murphy’s sign is suggestive of acute cholecystitis:

  • Place a hand in RUQ and apply pressure
  • Ask the patient to take a deep breath in
  • The gallbladder will move downwards during inspiration and come in contact with your hand
  • Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

 

Imaging

The first step is an abdominal ultrasound scan. Signs of acute cholecystitis on ultrasound are:

  • Thickened gallbladder wall
  • Stones or sludge in gallbladder 
  • Fluid around the gallbladder

 

Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

 

Management

Patients with suspected acute cholecystitis need emergency admission for investigations and management.

Conservative management involves:

  • Nil by mouth
  • IV fluids
  • Antibiotics (as per local guidelines)
  • NG tube if required for vomiting

 

Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct.

Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.

 

Complications

  • Sepsis
  • Gallbladder empyema
  • Gangrenous gallbladder
  • Perforation

 

Gallbladder Empyema

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options:

  • Cholecystectomy (to remove the gallbladder)
  • Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

 

Last updated May 2021