Cholecystitis

Overview – Cholecystitis

Cholecystitis refers to inflammation of the gallbladder, commonly caused by obstruction of the cystic duct by gallstones. It can present as acute or chronic, and is a significant complication of cholelithiasis. Prompt diagnosis and management are essential to prevent life-threatening complications such as perforation or gangrene.

Acute Cholecystitis

Definition: Biliary pain lasting >3 hours due to gallbladder inflammation

Aetiology

• 90% – Gallstone impaction in the cystic duct
  • Risk Factors:
    • Female sex
    • Age
    • Obesity
    • Pregnancy
    • Rapid weight loss
    • Certain medications
• 10% – Acalculous cholecystitis
  • Often seen in critically ill patients or following trauma, sepsis, or prolonged fasting

Pathogenesis

• Calculous (90%):
  • Gallstones obstruct the cystic duct → bile stasis → gallbladder distension
  • Secondary infection (e.g. E. coli) → acute inflammation
• Acalculous (10%):
  • Gallbladder stasis due to prolonged parenteral feeding, trauma, or critical illness
  • Secondary infection contributes to inflammation

Morphology

• Distended, red, inflamed gallbladder
• May be palpable as an RUQ mass

Clinical Features

• Initial symptoms:
  • RUQ colicky pain → radiates to right scapula
  • Worsened by food intake
  • Nausea, vomiting
  • Fever, tachycardia
• Later signs:
  • Constant RUQ pain
  • Signs of peritonitis: guarding, rebound tenderness
  • Murphy’s Sign: inspiratory arrest on deep palpation
  • Jaundice (if biliary obstruction)

Investigations

• ↑Alkaline phosphatase (biliary obstruction)
• Abdominal ultrasound – 1st line and definitive
• ERCP – Diagnostic and therapeutic (stone removal, stenting)

Complications

• Gangrenous cholecystitis (from increased intraluminal pressure)
• Empyema – pus in the gallbladder
• Gallbladder perforation
• 30% may require emergency surgery

Treatment

• Nil by mouth (bowel rest)
• IV fluids and rehydration
• IV antibiotics
• Analgesia
• Cholecystectomy – definitive management

Chronic/Recurrent Cholecystitis

Definition: Recurrent gallbladder inflammation due to chronic obstruction

Aetiology

• “Biliary gravel” – small stones and sludge
• Thick bile predisposes to stone formation and chronic stasis

Pathogenesis

• Repeated obstruction → bile stasis
• Chronic inflammation of the gallbladder wall
• Gradual fibrosis and loss of gallbladder function

Clinical Features

• Chronic RUQ discomfort after meals
• Indigestion, bloating, post-prandial fullness
• Often mild and vague in presentation

Management

• Elective cholecystectomy – curative

Summary – Cholecystitis

Cholecystitis is a common and clinically significant cause of right upper quadrant pain, most often resulting from gallstone obstruction of the cystic duct. Acute cholecystitis may progress rapidly to complications such as perforation or gangrene if not recognised and managed promptly, while chronic cholecystitis presents with vague, postprandial discomfort and is linked to recurrent biliary stasis. Early diagnosis with ultrasound and appropriate intervention, including cholecystectomy, can prevent serious outcomes. For a broader context, see our Gastrointestinal Overview page.