What is acute cholecystitis?
Acute cholecystitis is a sudden inflammation (swelling) of the gallbladder. It usually develops as a complication of gallstones, in which case it is called calculous cholecystitis; in the absence of gallstones it is called acalculous cholecystitis.
Acute cholecystitis is a potentially life-threatening condition, which is usually treated by surgical gallbladder removal but nonsurgical treatment may be also effective.
Symptoms and Signs
Symptoms of acute cholecystitis can include [1,3,18]:
- Sudden severe pain in the right upper or central abdomen, which initially builds up to a certain level, remains constant and lasts for 6 hours to few days; the pain can be referred to the right middle back or right shoulder; the pin can appear 30 minutes to a couple hours after a heavy meal
- Nausea or vomiting that occurs only when pain occurs
NOTE: If you have a gallbladder attack lasting for more than 6 hours, go to a doctor as soon as possible to prevent eventual complications.
In children and elderly, acute cholecystitis may cause only nonspecific symptoms, such as anorexia and malaise without typical abdominal pain .
Below your rib cage on the right side, a doctor may palpate a lump, which can be tender to touch, especially when you breathe in (Murphy’s sign).
Mild jaundice can be present but apparent jaundice is more likely due to a liver or common bile duct problem than cholecystitis .
Note, that a physical examination in acute cholecystitis may reveal no abnormalities at all.
Chart 1. Gallstones (Cholelithiasis) vs Acute Cholecystitis
|Gallstones Only (Cholelithiasis)||Acute Cholecystitis|
|Pain duration||<6 hours||>6 hours|
Chart 1. *RUQ = right upper abdominal quadrant
Causes and Risk Factors
The main cause of acute cholecystitis is a gallstone stuck in the cystic duct, which leads out of your gallbladder . About 10% of individuals who have recurrent pain due to gallstones develop acute cholecystitis . Rarely, cholecystitis can be caused by a gallbladder polyp or cancer obstructing the cystic duct.
Risk factors for acute cholecystitis [1,13,16]:
- Age >60
- Underlying conditions: heart disease or diabetes mellitus
- A history of a stroke
- In children: congenital gallbladder disorders, sickle cell anemia
An abdominal ultrasound can detect acute cholecystitis with 95% sensitivity and differentiate it from other conditions with 80% specificity . It usually shows gallstones, a distended gallbladder with a thick wall and fluid around the gallbladder [2,6].
Cholescintigraphy (HIDA scan) is usually performed only when the results of ultrasonography are not certain; it can reveal blockage of the cystic duct [4,6].
Blood tests may reveal an increased number of white blood cells (WBC) and, when the common bile duct is blocked, increased liver enzymes and bilirubin . These test results are not specific for acute cholecystitis, though.
Computed tomography (CT) and magnetic resonance imaging (MRI) can both detect cholecystitis but are usually performed only to check for eventual other abdominal conditions . MRI can also differentiate between acute and chronic cholecystitis .
Common conditions that can mimic gallbladder inflammation include biliary colic without inflammation (pain lasts <6 hours), cholangitis (infection of the bile duct), trapped gas, acute gastritis, peptic ulcer, acute pancreatitis, viral hepatitis, kidney stones, pleurisy and heart attack .
To reduce pain during a gallbladder attack, avoid heavy meals and fatty foods.
Examples of foods to avoid are fried and spicy foods, vegetable oils, pies, sausages, chocolate, dairy, cakes, pasta and other high-calorie foods .
In the hospital, you can expect to receive intravenous feeding and consume nothing by mouth for few days .
If you have uncomplicated acute cholecystitis without fever or signs of bile duct blockage, you are younger than 70 years and otherwise healthy, you may not need surgery [8,10].
Conservative treatment, which includes bed rest, intravenous feeding (no food by mouth), painkillers and antibiotics, can last for few days.
Commonly prescribed pain medications for acute cholecystitis include [3,11]:
- Opiates: meperidine (pethidine), hydrocodone and a combination of oxycodone and acetaminophen (side effects: nausea, drowsiness)
- Nonsteroidal anti-inflammatory drugs: diclofenac, indomethacin, ketorolac (side effect: stomach irritation)
Doctors also commonly prescribe antibiotics, but it seems they are often not necessary [14,15].
There seems to be no reliable information about the effectiveness of natural home remedies, such as turmeric, apples or lemon juice, in the treatment of acute cholecystitis.
A surgical removal of the gallbladder is the most commonly recommended treatment for acute cholecystitis.
In uncomplicated cases, a doctor will usually suggest a minimally invasive laparoscopic surgical removal of the gallbladder. According to some studies, surgery has the best outcome when it is performed within 72 hours after onset of symptoms [8,12]. Laparoscopic surgery can also be done in women in any pregnancy trimester .
In complicated acute cholecystitis, a doctor will likely suggest you an open abdominal surgery within 48 hours.
When surgery is not possible due to a severe underlying condition, a doctor can perform gallbladder drainage (percutaneous cholecystostomy) via a catheter inserted through the abdominal wall. This procedure improves symptoms in about 75% of cases .
The risk of cholecystitis complications increases with age, underlying diseases and treatment delay . Life-threatening complications include [1,9,18]:
- Gallbladder infection (empyema)
- Gallbladder gangrene (in up to 20% cases)
- Gallbladder perforation (in up to 15% cases)
- Blood infection (sepsis)
- The collection of air in the gallbladder (emphysematous cholecystitis)
Uncomplicated acute cholecystitis has an excellent prognosis; most individuals recover within a week even without surgery [1,3].
The overall mortality rate for acute cholecystitis is 4% .
When the gallbladder is not removed, acute cholecystitis may recur within the next few months or years .
Recurrent acute cholecystitis may result in chronic cholecystitis.
- Bloom AA, Cholecystitis overview Emedicine
- Ansaloni L et al, 2016, WSES guidelines on acute calculous cholecystitis World Journal of Emergency Surgery
- Siddiqui AA, Acute cholecystitis MSD Manual, Professional version
- Hughes SJ, Gallstones and acute cholecystitis Clinical Advisor
- Wang CH et al, 2014, Long-term outcome of patients with acute cholecystitis receiving antibiotic treatment: a retrospective cohort study PubMed
- Bloom AA, Cholecystitis workup Emedicine
- Altun E et al, 2007, Acute Cholecystitis: MR Findings and Differentiation from Chronic Cholecystitis
- Bloom AA, Cholecystitis treatment Emedicine
- Indar AA et al, 2002, Acute cholecystitis PubMed
- Barak O et al, 2009, Conservative Treatment for Acute Cholecystitis: Clinical and Radiographic Predictors of Failure The Israel Medical Association Journal
- Bloom AA, Cholecystitis medication Emedicine
- Gurusamy K et al, 2013, Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis Cochrane
- Steel PAD, Acute cholecystitis and biliary colic Emedicine
- van Dijk AH et al, 2016, Systematic review of antibiotic treatment for acute calculous cholecystitis PubMed
- Yoshida M et al, 2007, Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines PubMed
- Cho JY et al, 2010, Risk factors for acute cholecystitis and a complicated clinical course in patients with symptomatic cholelithiasis PubMed
- Zakko SF et al, Acute cholecystitis: Pathogenesis, clinical features, and diagnosis UpToDate
- Zakko SF et al, Clinical features and diagnosis of acute cholecystitis, University of Alberta