Acute cholecystitis – Symptoms, diagnosis and treatment

acalculous cholecystitis
acalculous cholecystitis

Summary

Acute cholecystitis is a major complication of cholelithiasis (i.e., gallstones); symptomatic gallstones are common before developing cholecystitis.

Patients typically present with pain and localised tenderness, with or without guarding, in the upper right quadrant.

There may be evidence of a systemic inflammatory response with fever, elevated white cell count, and raised C-reactive protein.

Ultrasound is the definitive initial test. Magnetic resonance cholangiopancreatography may be required. In a patient with suspected sepsis, use computed tomography (or magnetic resonance imaging)to identify the cause.

Treatment is with antibiotics, analgesia, and fluid resuscitation as required, likely to be followed by an early cholecystectomy.

Definition

Acute cholecystitis is acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones. It develops in up to 10% of patients with symptomatic gallstones.[1] In most cases (90%), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall.[1] In 5% of cases, bile inspissation (due to dehydration) or bile stasis (due to trauma or severe systemic illness) can block the cystic duct, causing an acalculous cholecystitis.[1][Figure caption and citation for the preceding image starts]: The biliary tree [Citation ends].

History and exam

Key diagnostic factors

  • pain in the upper right quadrant
  • tenderness in the right upper quadrant
  • signs and symptoms of inflammation
  • palpable mass
  • presence of risk factors

Other diagnostic factors

  • fever/chills
  • nausea
  • right shoulder pain
  • anorexia
  • vomiting
  • jaundice

Risk factors

  • gallstones
  • physical inactivity
  • low fibre intake
  • severe illness
  • trauma
  • severe burns
  • total parenteral nutrition (TPN)
  • diabetes
  • ceftriaxone
  • ciclosporin
  • hepatic arterial embolisation
  • infections

Diagnostic investigations

1st investigations to order

  • CT or MRI of the abdomen
  • abdominal ultrasound
  • FBC
  • CRP
  • bilirubin
  • LFTs
  • serum lipase or amylase
  • blood cultures and/or bile cultures

Investigations to consider

  • magnetic resonance cholangiopancreatography (MRCP)
  • endoscopic ultrasound (EUS)

Treatment algorithm

Contributors

Expert advisers

John Abercrombie, FRCS

General and Colorectal Surgeon

Queen’s Medical Centre

Nottingham

UK

Biography

JA is Clinical Lead for General Surgery, Getting It Right First Time.

Disclosures

JA is a member of the Council of The Royal College of Surgeons of England and Clinical Lead for General Surgery, Getting It Right First Time. JA provides expert advice regarding suitability of surgical treatments for Spire Healthcare.

Acknowledgements

BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:

Charles Bellows MD

Professor of Surgery

University of New Mexico School of Medicine

Albuquerque

NM

Disclosures

CB is an author of one study referenced in this topic. CB declares that he has no other competing interests.

Peer reviewers

Christian Macutkiewicz, MD, FHEA, FRCS

Consultant General and Hepato-Pancreato-Biliary Surgeon

Clinical Lead for Emergency General Surgery, Gastrointestinal Medicine, and Surgery CSU

Manchester Royal Infirmary

Manchester

Director of Scientific Programme

Association of Surgeons of Great Britain and Ireland

UK

Disclosures

CM declares that he has no competing interests.

Editors

Emma Quigley

Section Editor, BMJ Best Practice

Disclosures

EQ declares that she has no competing interests.

Sue Mayor

Lead Section Editor, BMJ Best Practice

Disclosures

SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including NICE, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, NCEPOD, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare, and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.

Tannaz Aliabadi-Oglesby

Lead Section Editor, BMJ Best Practice

Disclosures

TAO declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Expert advisers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People’s Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Head of MBChB

School of Medicine

University of Leeds

Leeds

UK

Disclosures

AL has been the principal applicant/co-applicant for a number of grants including: Engineering and Physical Sciences Research Council Research – Multiplexed AKI biomarker detection with a single molecule biosensor; Leeds Cares – A novel, non-invasive diagnostic approach to assess kidney transplant health through the targeted measurement of biomarkers of kidney injury and immune response in kidney transplant recipients at the Leeds Teaching Hospitals NHS Trust; Kidney Research Yorkshire – Use of enhanced technology to characterise haemodialysis treatment for acute kidney injury (AKI); Bringing It Home – Validation of a micro-sampling technique for measuring tacrolimus and creatinine remotely; and to fund a research nurse; British Renal Society – Renal function assessment with point of care creatinine in diverse populations (RAPID), and several NIHR grants including on a) Improving the quality of post-discharge care following AKI b) An investigation into the use of remote blood sample collection to reduce health inequalities in patients with mental health disorders c) A comparison of remote blood collection devices: a human factor use study d) Defining the characteristics for a novel automatic device to monitor urine output in catheterized patients e) Leeds Medtech and In-vitro Diagnostic Cooperative Grant Extension f) Surgical MedTech Co-operative for the 2019/20 proof-of-principle funding stream g) A pilot investigation into the use of beta-trace protein for residual renal function estimation in haemodialysis h) Application of functional MRI to improve assessment of chronic kidney disease (AFiRM study) i) SuperResPath-Renal: Quantitative super-resolution technology for a fast, decentralised clinical diagnosis of renal pathologies. AL is the co-author of a number of manuscripts including on extracorporeal treatments, AKI, kidney function testing prior to contrast-enhanced CT, plasma exchange and glucocorticoids in severe ANCA-associated vasculitis, COVID-19 rapid diagnostics, multimodal image-guided ablation on management of renal cancer in Von-Hippel-Lindau syndrome, and on a summary of NICE guidance on CKD. AL is the author of several book chapters on nephrology and AKI. AL has received expenses for accommodation and travel for conferences at which he has given lectures, other than those delivered virtually. AL was a member of the AKI Scientific Program Committee for the ISN World Congress of Nephrology 2020-2021 and Chair of this same committee in 2021-2022.

Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

UK

Disclosures

MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, & Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

RAE has given lectures for non-promotional industry-led sessions on long COVID and provided consultancy for GSK, AstraZenica, Boehringer, and Chiesi, for individual payment and travel expenses totalling <£4000.

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Disclosures

GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.

Sotiris Posporelis, MD, MRCPsych

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

UK

Disclosures

SP declares that he has no competing interests.

Hamish McAuley, MBBS, BSc, MRCP

Clinical Research Fellow

Specialist Registrar (ST5)

Department of Respiratory Sciences

University of Leicester

Respiratory Biomedical Research Unit

Glenfield Hospital

Leicester

UK

Disclosures

HM declares that he has no competing interests.

Asangaedem Akpan, MPH, FRC

Consultant Geriatrician

Liverpool University Hospitals NHS Foundation Trust

Visiting Professor

University of Cumbria

Carlisle

Honorary Clinical Associate Professor

University of Liverpool

Liverpool

UK

Disclosures

AA has received honorariums for giving lectures on behalf of Profile Pharma in 2021. AA is an expert committee member of the National Institute for Health and Care Excellence (NICE) quality standards committee on urinary tract infections in adults and Deputy chair of the British Geriatrics Society England Council and Ageing Specialty Research Lead CRN NWC. AA sits on advisory committees for the following research studies: VOICE2 (development and testing of communication skills training for hospital healthcare practitioners caring for people living with dementia), SWOP (social work in older people) and CFIN (cognitive frailty interdisciplinary network). AA has received research funding from the Liverpool CCG and Applied Research Collaborative. He is contributing to developing a heart failure pathway tool for the British Society for Heart Failure and has been invited to contribute to the European Union Geriatric Medicine conference (free conference registration) and British Society for Heart Failure conference (accommodation and travel expenses covered).

Acknowledgement: Professor Sanjay Agrawal

BMJ Best Practice would like to gratefully acknowledge Professor Sanjay Agrawal, National Speciality Advisor for tobacco dependency at NHS England and Chair of Royal College of Physicians tobacco advisory group, for his advice on the comorbidity content for ‘current smoker’.

Professor Sanjay Agrawal, MBChB, FRCP

Consultant in Respiratory and Intensive Care Medicine

University Hospitals of Leicester NHS Trust

Leicester

UK

Disclosures

SA declares that he has no competing interests.

Peer reviewers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People’s Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.

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