Acute Cholecystitis

Acute cholecystitis is acute inflammation of the gallbladder and represents one of the most common complications of gallstone disease (Lammert & Wittenburg, Seminars in Liver Disease, 2024). Gallstone-associated obstruction of the cystic duct is responsible for 90% to 95% of cases, with the remaining 5% to 10% being acalculous (without stones) and occurring mainly in critically ill patients (Gallaher & Charles, JAMA, 2022). It is a frequent cause of abdominal pain in the emergency department, accounting for roughly 7% of all patients presenting with abdominal pain (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

The central distinction for patients is that acute cholecystitis is not the same as a routine gallbladder attack. In biliary colic, a stone transiently blocks the gallbladder outlet and the pain resolves within a few hours once the stone falls back. In acute cholecystitis, the obstruction persists, the gallbladder wall becomes inflamed and progressively swollen, and — in about 20% of cases — a secondary bacterial infection develops (Gallaher & Charles, JAMA, 2022). Left untreated, inflammation can progress through hemorrhage, necrosis (gangrene), and eventually perforation of the gallbladder, which is why timely recognition and treatment matter (Gallaher & Charles, JAMA, 2022).

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Acute cholecystitis develops when the cystic duct becomes obstructed and the gallbladder cannot empty (Gallaher & Charles, JAMA, 2022):

• Gallstones (calculous cholecystitis) — the cause in 90–95% of cases; a stone, sludge, or lithogenic bile obstructs the cystic duct, raising intraluminal pressure and triggering an acute inflammatory response (Gallaher & Charles, JAMA, 2022).

• Secondary bacterial infection — enteric organisms (most commonly Escherichia coli, Klebsiella, and Streptococcus faecalis) are involved in about 20% of cases, superimposed on the initial sterile inflammation (Gallaher & Charles, JAMA, 2022).

• Acalculous cholecystitis — accounts for 5–10% of adult cases (and over half of pediatric cases); it arises without stones, typically in severely ill patients, from bile stasis (fasting, ileus) and ischemia of the gallbladder wall caused by low blood flow (Gallaher & Charles, JAMA, 2022; Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

Because gallstones underlie the overwhelming majority of cases, the risk factors for acute cholecystitis are essentially those for gallstone disease (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

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The risk factors mirror those for gallstones (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023; Gallaher & Charles, JAMA, 2022):

• Age over 40

• Female sex — women are more than twice as likely to be affected

• Obesity (greater than ~120% of ideal body weight) and excess visceral fat

• Pregnancy

• Oral contraceptive or estrogen replacement use

• Rapid weight loss or crash dieting

• Diabetes and the metabolic syndrome

• Ethnicity — higher rates in Native American and Hispanic populations

• Critical illness, prolonged fasting, and total parenteral nutrition — specifically for acalculous cholecystitis (Gallaher & Charles, JAMA, 2022)

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The gallbladder stores and concentrates bile and releases it to help digest fats (Kim & Donahue, JAMA, 2018). When a stone obstructs the cystic duct, bile cannot escape; intraluminal pressure rises and, together with cholesterol-supersaturated bile, sets off inflammation of the gallbladder wall (Gallaher & Charles, JAMA, 2022).

If the obstruction persists, acute cholecystitis progresses through three recognized phases (Gallaher & Charles, JAMA, 2022):

• Phase 1 (2–4 days) — inflammation with wall congestion and edema.

• Phase 2 (3–5 days) — hemorrhage and necrosis of the gallbladder wall, which can lead to perforation at a site of ischemic gangrene and subsequent bile peritonitis.

• Phase 3 (day 6 or later) — the chronic/purulent phase, with leukocyte infiltration, necrotic tissue, intraluminal pus, and gross infection.

This stepwise progression is the reason early intervention is favored — the longer the gallbladder remains obstructed and inflamed, the higher the risk of serious complications (Gallaher & Charles, JAMA, 2022).

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Untreated or severe acute cholecystitis can lead to (Gallaher & Charles, JAMA, 2022; Walter, JAMA, 2022):

• Gangrenous cholecystitis — necrosis of the gallbladder wall

• Gallbladder perforation and bile peritonitis — a surgical emergency

• Empyema of the gallbladder — pus-filled, infected gallbladder

• Emphysematous cholecystitis — gas-forming infection, more common in diabetics

• Sepsis — from a severe gallbladder infection

• Cholecystoenteric fistula and gallstone ileus — a stone eroding into and obstructing the bowel

• Associated biliary complications — concurrent choledocholithiasis, cholangitis, or gallstone pancreatitis when stones migrate into the common bile duct (Baiu & Hawn, JAMA, 2018)

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The typical presentation is persistent right-upper-quadrant pain, fever, and nausea (Gallaher & Charles, JAMA, 2022):

• Pain — constant, severe right-upper-quadrant or epigastric pain that lasts more than 5–6 hours (distinguishing it from biliary colic), often beginning after a meal and sometimes radiating to the right shoulder or scapula (Gallaher & Charles, JAMA, 2022; Patel & Jepsen, American Family Physician, 2024).

• Fever — low-grade or higher, reflecting inflammation and possible infection (Walter, JAMA, 2022).

• Nausea and vomiting, often related to eating (Gallaher & Charles, JAMA, 2022).

• Murphy's sign — right-upper-quadrant tenderness with an inspiratory pause on palpation, a characteristic examination finding (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

Jaundice (yellowing of the eyes or skin) is not typical of simple cholecystitis and should raise suspicion for a bile duct stone (choledocholithiasis) or cholangitis (Baiu & Hawn, JAMA, 2018).

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Diagnosis combines the clinical picture with imaging and laboratory testing (Gallaher & Charles, JAMA, 2022):

• Right-upper-quadrant ultrasound — the first-line test, with a sensitivity of ~81% and specificity of ~83%; findings include gallstones, a thickened gallbladder wall, pericholecystic fluid, and a sonographic Murphy's sign (Gallaher & Charles, JAMA, 2022; Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

• Hepatobiliary scintigraphy (HIDA scan) — the gold-standard test when ultrasound is not definitive; nonvisualization of the gallbladder indicates cystic duct obstruction (Gallaher & Charles, JAMA, 2022).

• Laboratory tests — white-cell count and inflammatory markers are often elevated; liver tests and bilirubin are usually normal in uncomplicated cholecystitis, and abnormal results suggest a coexisting bile duct problem (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023; Baiu & Hawn, JAMA, 2018).

• CT or MRI — helpful for diagnosing complications or clarifying atypical presentations (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

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Persistent right-upper-quadrant pain with fever must be distinguished from (Gallaher & Charles, JAMA, 2022; Patel & Jepsen, American Family Physician, 2024):

• Biliary colic (uncomplicated, self-limited gallbladder attack)

• Choledocholithiasis, cholangitis, and gallstone pancreatitis (related biliary complications)

• Peptic ulcer disease and gastritis

• GERD / hiatal hernia and functional dyspepsia

• Acute hepatitis

• Right lower-lobe pneumonia

• Acute appendicitis (especially retrocecal or in pregnancy)

• Right-sided renal colic or pyelonephritis

• Myocardial infarction — particularly with epigastric presentation

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Acute cholecystitis is an acute, often emergency condition that is treated procedurally, not with lifestyle change; however, the same measures that reduce gallstone formation lower the risk of developing it in the first place (Lammert & Wittenburg, Seminars in Liver Disease, 2024):

• Maintain a healthy weight and avoid rapid/crash weight loss — and when major weight loss is planned (including after bariatric surgery), ursodeoxycholic acid can reduce gallstone formation (Lammert & Wittenburg, Seminars in Liver Disease, 2024).

• Favor a lower-refined-fat, higher-fiber diet and manage metabolic risk factors (diabetes, dyslipidemia) (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

Once acute cholecystitis is diagnosed, diet and lifestyle changes cannot substitute for definitive treatment — the inflamed, obstructed gallbladder needs to be addressed (Gallaher & Charles, JAMA, 2022).

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Treatment combines initial supportive care with definitive source control (Gallaher & Charles, JAMA, 2022; Lammert & Wittenburg, Seminars in Liver Disease, 2024):

• Initial management — hospital admission, intravenous fluids, pain control, bowel rest, and antibiotics covering enteric organisms (Fischmann & Bellolio, Evidence-Based Emergency Care, 2023).

• Early laparoscopic cholecystectomy — the definitive, gold-standard treatment. Early surgery (within 1–3 days) is superior to delayed surgery, with fewer composite postoperative complications (11.8% vs 34.4%), shorter hospital stay (5.4 vs 10.0 days), and lower cost; several guidelines recommend performing it early, ideally within 24 hours of admission (Gallaher & Charles, JAMA, 2022; Lammert & Wittenburg, Seminars in Liver Disease, 2024).

• During pregnancy — early laparoscopic cholecystectomy is recommended in all trimesters, as it lowers maternal-fetal complications compared with delayed management (1.6% vs 18.4%) (Gallaher & Charles, JAMA, 2022).

• Older adults — laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) than nonoperative management (29.3%), so surgery should not be withheld on age alone (Gallaher & Charles, JAMA, 2022).

• Percutaneous cholecystostomy tube — a drainage catheter placed into the gallbladder under imaging, reserved for patients at exceptionally high perioperative risk; in a randomized trial it had higher postprocedural complication rates (65%) than laparoscopic cholecystectomy (12%), so it is a bridge/rescue option rather than first choice (Gallaher & Charles, JAMA, 2022).

• Acalculous cholecystitis — percutaneous cholecystostomy is reserved for those who are severely ill at diagnosis; all others should undergo laparoscopic cholecystectomy (Gallaher & Charles, JAMA, 2022).

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Anyone with upper-abdominal pain that lasts more than a few hours, especially with fever, nausea, or vomiting, should be evaluated promptly, since persistent pain signals that a gallbladder attack has progressed beyond simple biliary colic (Gallaher & Charles, JAMA, 2022). A first episode of biliary pain — even once resolved — also warrants evaluation, as it often heralds gallstone disease that tends to recur and can progress to cholecystitis (Lammert & Wittenburg, Seminars in Liver Disease, 2024).

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Seek emergency care for (Walter, JAMA, 2022; Patel & Jepsen, American Family Physician, 2024):

• Severe right-upper-quadrant or epigastric pain lasting more than 5–6 hours

• Fever or chills

• Persistent vomiting and inability to keep down fluids

• Jaundice (yellow eyes/skin), dark urine, or clay-colored stools — suggesting a bile duct stone or cholangitis

• Confusion, low blood pressure, or rapid heart rate — possible signs of sepsis from a gallbladder infection

These features indicate a surgical emergency requiring hospital evaluation, imaging, antibiotics, and usually prompt gallbladder removal (Gallaher & Charles, JAMA, 2022; Baiu & Hawn, JAMA, 2018).

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After laparoscopic gallbladder removal, the long-term outlook is very good: the gallbladder is not essential for digestion, bile simply flows directly from the liver into the intestine, and most patients resume a normal, unrestricted diet (Kim & Donahue, JAMA, 2018). A minority experience transient loose stools or diarrhea that typically resolves over weeks to months, and serious bile-duct injuries are rare (Kim & Donahue, JAMA, 2018). Because removing the gallbladder eliminates the organ where stones form, it is definitive — it both resolves the current episode and prevents future gallbladder attacks (Baiu & Hawn, JAMA, 2018).

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With timely diagnosis and early laparoscopic cholecystectomy, the prognosis for acute cholecystitis is excellent, and outcomes are measurably better than with delayed surgery or nonoperative management (Gallaher & Charles, JAMA, 2022). The risks rise with delay, advanced age, diabetes, and the development of complications such as gangrene or perforation, which is why early intervention is emphasized (Gallaher & Charles, JAMA, 2022). Patients managed with a cholecystostomy tube because they are too ill for immediate surgery can be stabilized and often undergo cholecystectomy later once their condition improves (Gallaher & Charles, JAMA, 2022).

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Acute cholecystitis is a time-sensitive condition in which early, expert surgical evaluation changes outcomes — the data clearly favor early laparoscopic cholecystectomy over delay (Gallaher & Charles, JAMA, 2022). As a board-certified surgeon with advanced expertise in minimally invasive and robotic foregut and biliary surgery, Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM provides rapid assessment with ultrasound and targeted labs, distinguishes uncomplicated cholecystitis from bile duct complications that require additional intervention, and performs minimally invasive (laparoscopic/robotic) cholecystectomy with strict adherence to safe-cholecystectomy principles to minimize the risk of bile-duct injury (Gallaher & Charles, JAMA, 2022; Kim & Donahue, JAMA, 2018). For patients who are initially too ill or high-risk for immediate surgery, he coordinates appropriate temporizing measures such as percutaneous drainage as a bridge to definitive treatment, and counsels patients candidly on timing, recovery, and realistic expectations (Gallaher & Charles, JAMA, 2022).

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