Acute cholecystitis

Last updated: August 24, 2023

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Summarytoggle arrow icon

Acute cholecystitis refers to the acute inflammation of the gallbladder, which is typically due to cystic duct obstruction by a gallstone (acute calculous cholecystitis). Acalculous cholecystitis is less common and is seen predominantly in critically ill patients. RUQ pain, a positive Murphy sign, and fever are the characteristic clinical features of acute cholecystitis. RUQ ultrasound is the preferred initial imaging modality, which would show gallbladder distension, edema, and pericholecystic fluid. Empiric antibiotic therapy and laparoscopic cholecystectomy are the mainstays of treatment. Laparoscopic cholecystectomy should be performed as soon as possible, preferably within 72 hours of admission, unless operative and anesthesia risks outweigh the benefits of urgent surgery. In high-risk patients with severe cholecystitis, a temporizing gallbladder drainage procedure (e.g., percutaneous cholecystostomy, endoscopic gallbladder stenting) should be performed and elective interval cholecystectomy scheduled after the resolution of acute symptoms. Complications of acute cholecystitis include gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation, biliary-enteric fistula, gallstone ileus, and pyogenic liver abscess. Chronic cholecystitis may result from recurrent attacks of acute cholecystitis or due to chronic cholelithiasis. Chronic gallbladder inflammation increases the risk of gallbladder carcinoma.

See also “Cholelithiasis”, “Choledocholithiasis”, and “Acute cholangitis.”

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Approximately 90% of acute cholecystitis is caused by cholelithiasis. Acalculous cholecystitis accounts for the remaining 10%. [4]

Clinical featurestoggle arrow icon

Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis

Subtypes and variantstoggle arrow icon

Acute acalculous cholecystitis [3][7][8][9]

Suspect acalculous cholecystitis in any critically ill patient with fever and RUQ tenderness.

Emphysematous cholecystitis (EC) [8][11][12]

Diagnosticstoggle arrow icon

The diagnosis of acute cholecystitis is based on characteristic clinical features, systemic signs of inflammation (leukocytosis, CRP),; and evidence of gallbladder inflammation on imaging.

Fever and tachycardia are commonly absent in acute cholecystitis; maintain a high index of clinical suspicion! [15]


Diagnostic criteria for acute cholecystitis [11]
Local signs of inflammation
Systemic signs of inflammation
Imaging findings
  • Any imaging finding characteristic of acute cholecystitis (see ''Imaging'' section)
  • Suspected diagnosis: ≥ 1 local sign of inflammation PLUS ≥ 1 systemic sign of inflammation
  • Definite diagnosis: ≥ 1 local sign of inflammation PLUS ≥ 1 sign of systemic inflammation PLUS any characteristic imaging finding

Laboratory studies [11][16]

Imaging [10][11]

RUQ transabdominal ultrasound

See also “Biliary point-of-care ultrasound.”

Cholescintigraphy [3][10][21]

Commonly referred to as hepatobiliary iminodiacetic acid scintigraphy or a HIDA scan.

MRI abdomen without and with IV contrast [10][20][23]

CT abdomen with IV contrast [3][8]

Severity gradingtoggle arrow icon

Stratify the severity of acute cholecystitis to determine the best approach to treatment. [11][24]

Severity grading of acute cholecystitis [11]
Grades of severity Grading criteria

Grade I

(Mild acute cholecystitis)

Grade II

(Moderate acute cholecystitis)

  • No evidence of organ dysfunction
  • Presence of at least one of the following signs of severe gallbladder disease:
    • Symptom duration > 72 hours
    • WBC count > 18,000/mm3
    • Palpable tender RUQ mass
    • Signs of significant local inflammation on imaging studies

Grade III

(Severe acute cholecystitis)

Treatmenttoggle arrow icon

Empiric antibiotic therapy and cholecystectomy are the mainstays of treatment for acute cholecystitis after initial supportive therapy.

Initial management [17][24][25]

Definitive management [24][25][26][27]

The initial procedure and duration of antibiotic therapy depend on severity grading of acute cholecystitis, patient's individual surgical risk, and presence of complications.

Perform preoperative or postoperative stone extraction in patients with concurrent choledocholithiasis.

Grade I acute cholecystitis

Grade II acute cholecystitis

Grade III acute cholecystitis


Laparoscopic cholecystectomy

  • Indication: gold standard of treatment for acute calculous cholecystitis [24]
  • Timing: depends on surgical and anesthesia risks, disease severity, and symptom duration
    • Early laparoscopic cholecystectomy: performed within 10 days of symptom onset; preferably within the initial 24–72 hours [24][26]
      • Indication: symptom duration of ≤ 10 days in patients with low surgical and anesthesia risk(s) [24]
      • Contraindications
        • High surgical or anesthesia risks
        • Symptom duration > 10 days
    • Interval laparoscopic cholecystectomy (delayed lap. chole)
      • Performed 45 days after resolution of symptoms [24]
      • Indications
        • High surgical or anesthesia risk
        • Symptom duration > 10 days

Gallbladder drainage

Disposition [25]

All patients with acute cholecystitis require inpatient management.

Antibiotic therapy for acute biliary infectiontoggle arrow icon

General principles [17]

Recommended empiric regimen [17]

Empiric antibiotic therapy for acute biliary infection
Class of infection Severity of infection

Suggested single-agent empiric regimen

Suggested combination empiric regimen

Community-acquired biliary infection

Grade I

Grade II

Grade III

Healthcare-associated biliary infection

(any grade)

  • Same as grade III community-acquired biliary infection [36]
Suspected multi-drug resistant organism infection
  • Same as grade III community-acquired biliary infection
  • PLUS any one of the following, depending on the suspected infection:

Many ESBL-producing gram-negative organisms are resistant to fluoroquinolones.

Resistance of E. coli to ampicillin-sulbactam is becoming more common, especially in North America. Consider local resistance rates carefully before choosing an empiric antibiotic regimen.

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

Gangrenous cholecystitis [8][37][38]

Gallbladder perforation [8][38][39]

Cholecystoenteric fistula

Gallbladder empyema (suppurative cholecystitis) [8]

Subhepatic abscess

Chronic cholecystitis [4][8][41]

Chronic gallbladder inflammation increases the risk of gallbladder carcinoma, especially when porcelain gallbladder is present.

Other [8]

We list the most important complications. The selection is not exhaustive.

ICD-10 codestoggle arrow icon

Referencestoggle arrow icon

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