Acute Cholecystitis
A gallstone impacts persistently at the cystic duct, so unlike transient biliary colic the gallbladder wall distends, becomes ischaemic and secondarily infected, producing continuous pain, fever and a positive Murphy's sign.
In a nutshell
Sustained, not transient, obstruction of the cystic duct distends and inflames the gallbladder wall, which is then often secondarily infected. This is why cholecystitis, unlike colic, produces pain beyond six hours, fever, a positive Murphy's sign and raised inflammatory markers, and why the fix is to remove the organ, early.
Classic presentation
Constant right upper quadrant pain for more than six hours with fever and a positive Murphy's sign, in a patient with known gallstones.
Key points
- Persistent, not transient, cystic duct obstruction is what separates cholecystitis from biliary colic mechanistically.
- Full-thickness wall inflammation irritates the overlying peritoneum, producing localised guarding and Murphy's sign.
- Fever and raised inflammatory markers reflect a true inflammatory/infective process, unlike the purely mechanical picture of colic.
- Ultrasound is first-line, showing a thickened wall, pericholecystic fluid and gallbladder distension.
- NICE recommends early laparoscopic cholecystectomy within one week, rather than delaying to a later elective date.
First-line investigation
Transabdominal ultrasound, looking for gallbladder wall thickening, pericholecystic fluid and an impacted stone.
First-line management
IV fluids, analgesia and antibiotics, followed by early laparoscopic cholecystectomy within one week of presentation.
Exam traps
- Pain lasting beyond six hours with fever is cholecystitis, not colic; do not send home for outpatient follow-up alone.
- Deranged LFTs in cholecystitis should raise suspicion of a concurrent CBD stone or Mirizzi syndrome, not be dismissed.
- Delaying cholecystectomy for weeks after acute cholecystitis is outdated practice; current guidance favours early surgery.
Educational content pending clinical review. Not medical advice.