Upper GI & Hepatobiliary Surgery

Acute Cholecystitis

Persistent cystic-duct obstruction inflames the gallbladder rather than causing transient biliary colic: assess for sepsis and common-bile-duct disease, give supportive and antimicrobial treatment when indicated, and arrange early source control.

In a nutshell

Acute cholecystitis is persistent gallbladder inflammation, usually from cystic-duct obstruction. Combine clinical assessment with LFTs and ultrasound, investigate jaundice or cholestasis for common-bile-duct stones, give supportive and antimicrobial treatment when indicated, and offer laparoscopic cholecystectomy within 1 week. Drainage is for selected patients in whom surgery is unsafe or unavailable.

Classic presentation

Constant right-upper-quadrant pain with fever or systemic inflammation, RUQ tenderness or a positive Murphy sign, and ultrasound evidence of gallstones or gallbladder inflammation.

Key points

Unlike biliary colic, acute cholecystitis is persistent inflammation: pain is constant and systemic inflammatory features are common.
NICE recommends liver-function tests and ultrasound for suspected gallstone disease; ultrasound is the first-line imaging test.
Jaundice, abnormal liver tests or a dilated bile duct should trigger MRCP, and EUS if MRCP is non-diagnostic, to assess for common-bile-duct stones.
Treat sepsis and give antibiotics when clinically indicated, using local antimicrobial policy and current BNF for agent, dose, renal adjustment and duration; antibiotics do not replace source control.
Offer early laparoscopic cholecystectomy within 1 week of diagnosis. Do not default to weeks of conservative treatment and delayed surgery.
If common-bile-duct stones are present, clear the duct surgically or with ERCP before or at cholecystectomy; a biliary stent is temporary if ERCP cannot clear the duct.
For empyema when surgery is contraindicated and conservative treatment fails, offer percutaneous cholecystostomy and reconsider surgery when fit. Specialist EUS-guided drainage is an option when surgery is not possible.
Peritonism, shock, organ dysfunction, emphysematous disease or failure to improve requires urgent senior surgical and critical-care escalation.

First-line investigation

Liver-function tests and transabdominal ultrasound, followed by MRCP or EUS if the bile duct is dilated or liver tests are abnormal despite no duct stone on ultrasound.

Management

Stabilise and assess severity

Use ABCDE, analgesia, fluids and antiemetics, keep nil by mouth while surgical assessment is underway, assess sepsis and monitor organ function; use BNF and local protocols for prescribing.^1,2,4,5,6

Confirm gallbladder disease and check the duct

Perform LFTs and ultrasound. If the bile duct is dilated or LFTs are abnormal without a detected duct stone, arrange MRCP and consider EUS if MRCP is non-diagnostic.¹

Treat infection and obtain source control

Give antimicrobial treatment when indicated by infection or sepsis using current local policy and BNF, then offer laparoscopic cholecystectomy within 1 week of diagnosis when the patient is suitable.^{1,10,2,4,7,8,9}

Drain or clear the biliary system selectively

Clear a common-bile-duct stone surgically or with ERCP before or at surgery. If surgery is contraindicated and conservative management fails in gallbladder empyema, use percutaneous cholecystostomy; specialist EUS-guided drainage is reserved for centres with the required expertise.^1,2,3

Prevent recurrence and recognise complications

Escalate peritonitis, gangrene, perforation, emphysematous disease, organ dysfunction or failure to improve; after recovery ensure definitive gallstone management and a documented surgical follow-up plan.^1,4,2

Exam traps

A positive Murphy sign and inflammatory markers support cholecystitis but do not exclude cholangitis, pancreatitis, perforation or another acute abdomen.
Jaundice or a markedly cholestatic liver-test pattern is not typical isolated cholecystitis; investigate the common bile duct.
Do not use a normal or equivocal ultrasound to overrule a deteriorating septic patient; escalate and consider alternative or complicated disease.
Antibiotics are supportive treatment, not definitive source control when the patient is fit for cholecystectomy.
Percutaneous cholecystostomy is not routine first-line treatment; NICE reserves it for empyema when surgery is contraindicated and conservative management has failed.
If early surgery within one week is not achievable, follow the NICE pathway and senior surgical decision-making rather than inventing an interval plan.
Gallstone pancreatitis and acute cholangitis have separate pathways; do not force every biliary presentation into acute cholecystitis.

Illustrations

Ultrasound features of acute cholecystitisGallbladder ultrasound demonstrating abnormal wall thickening, highlighted by arrows and calipers.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Eliciting Murphy's signClinical illustration of the examination technique for Murphy's sign, showing palpation under the right costal margin during inspiration.PassFinals · original

Gangrenous acute cholecystitis on histologyHistological section of gallbladder wall showing sloughed mucosa, necrosis and dense neutrophilic inflammation in gangrenous acute cholecystitis.Mikael Häggström, M.D., Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.