Acute cholecystitis
Formal Definition
Acute inflammation of the gallbladder, most commonly caused by obstruction of the cystic duct by a gallstone (calculous cholecystitis, ~90-95% of cases), leading to gallbladder distension, wall edema, ischemia, secondary bacterial infection, and characteristic right upper quadrant pain, fever, leukocytosis, and a positive Murphy's sign; diagnosis confirmed by ultrasound (gallstones, gallbladder wall thickening >4mm, pericholecystic fluid, sonographic Murphy's); treatment includes IV antibiotics, fluid resuscitation, analgesia, and either early laparoscopic cholecystectomy (within 72h, increasingly standard) or interval cholecystectomy after cooling off the inflammation if high surgical risk.
How It's Used on the Ward
"Acute cholecystitis" or "hot gallbladder" — the stone is stuck in the cystic duct, the gallbladder is angry and infected, and the patient has unrelenting RUQ pain (often radiating to the right shoulder/back), fevers, and nausea; ultrasound is the first test; the fix is laparoscopic cholecystectomy (lap chole), usually done within 72h of presentation.
Example
""45-year-old woman, BMI 35, presents with 36h of RUQ pain radiating to right shoulder, fever 38.7°C, nausea, vomiting, anorexia. Exam: tender RUQ, positive Murphy's sign (pain + inspiratory arrest with palpation under the right costal margin). WBC 14.2 with left shift. Lipase 88 (normal), LFTs mildly elevated. RUQ ultrasound: 8mm gallstone impacted at gallbladder neck, gallbladder wall 6mm, pericholecystic fluid. Diagnosis: acute calculous cholecystitis. Admitted, NPO, IV fluids, ceftriaxone + metronidazole, scheduled for laparoscopic cholecystectomy within 48h.""
Clinical Context
Diagnostic criteria (Tokyo Guidelines): (1) local: RUQ pain/tenderness, Murphy's sign, palpable RUQ mass; (2) systemic: fever, leukocytosis, elevated CRP; (3) imaging findings (US first-line, cholescintigraphy/HIDA if equivocal). Severity grading (TG13/TG18): Grade I (mild) — no organ dysfunction, cholecystectomy safe; Grade II (moderate) — elevated WBC >18,000, palpable tender RUQ mass, duration >72h, marked local inflammation; Grade III (severe) — organ dysfunction (CV, neuro, renal, hepatic, respiratory). Cholecystectomy timing: early (within 72h of presentation, ideally within 7 days of symptom onset) shown to be safe and reduces hospital stay vs interval (cooling off for 6-12 weeks then elective surgery). High-risk patients (elderly, multiple comorbidities): percutaneous cholecystostomy tube for drainage + interval cholecystectomy later. Acalculous cholecystitis (5-10%): critically ill, post-op, severe burns, TPN-dependent — high mortality. Complications: gangrenous cholecystitis, perforation, emphysematous cholecystitis (Clostridium, surgical emergency), cholecystoenteric fistula with gallstone ileus.