⚠️ Mortality: Acute calculous cholecystitis has a mortality of <10% with prompt treatment. However, 🔥 Acute Acalculous Cholecystitis (more common in the critically ill) carries a mortality rate of up to 50% 🚨 and requires urgent recognition and intervention.

🩺 Initial Management Summary
🔄 ABC: Assess airway, breathing, circulation. Start IV fluids (2–3L/day), analgesia, NBM (nil by mouth). 🧪 Investigations: FBC, U&E, LFT, CRP, blood cultures. Imaging → USS (first-line), CT if unclear. 💊 Antibiotics: IV broad-spectrum (e.g. Tazocin, cefuroxime + metronidazole) per local policy. 👨‍⚕️ Surgical Review: Early referral for cholecystectomy (preferably within 5 days).

🩺 Initial Management Summary

🔄 ABC: Assess airway, breathing, circulation. Start IV fluids (2–3L/day), analgesia, NBM (nil by mouth).
🧪 Investigations: FBC, U&E, LFT, CRP, blood cultures. Imaging → USS (first-line), CT if unclear.
💊 Antibiotics: IV broad-spectrum (e.g. Tazocin, cefuroxime + metronidazole) per local policy.
👨‍⚕️ Surgical Review: Early referral for cholecystectomy (preferably within 5 days).

ℹ️ About

📊 Prevalence: Gallstones affect ~10% of the population; 10–20% become symptomatic.
🧪 Pathophysiology: Gallstone obstructs cystic duct → ↑ pressure, bile stasis, gallbladder wall inflammation.
👩 Demographics: More common in women; incidence rises with age (♀24%, ♂15% by age 70).
🔪 Treatment: Symptomatic patients usually require laparoscopic cholecystectomy after excluding CBD stones.

🧪 Aetiology

💧 Lithogenic bile: ↑ cholesterol, ↓ bile salts → stone formation.
🚪 Cystic duct obstruction: Main trigger → inflammation.
🦠 Secondary infection: Often E. coli, Klebsiella, Enterococcus.
⚠️ Empyema: Severe complication = pus-filled gallbladder needing urgent surgery.

⚠️ Risk Factors

👵 Age >50, 👩 Female, Caucasian
🍔 Obesity, rapid weight loss, diabetes, metabolic syndrome
🧬 Crohn’s (terminal ileal disease), cholestyramine therapy
🤰 Pregnancy, cystic fibrosis

💎 Types of Gallstones

Type	Description	Incidence
⚪ Mixed	Cholesterol + bile salts + calcium; most common.	70%
🟡 Cholesterol	Solitary; linked with hyperlipidaemia, pregnancy; “strawberry gallbladder”.	20%
⚫ Pigment	Dark; associated with haemolysis (e.g. sickle cell).	5%
🟤 Brown	Linked with infection (e.g. Clonorchis) – rare in UK.	Rare

Cholecystitis by USS and CT abdomen

Oblique coronal US images show (a) a normal gallbladder (GB); and (b) a thickened GB wall and thin layer of pericholecystic fluid (arrowhead), with an impacted calculus in the neck of the GB (arrow) in a patient with acute cholecystitis. LI: liver

(a) a thickened enhancing gallbladder wall, pericholecystic fat stranding (white arrow) and reactive hyperaemia in the adjacent liver (black arrow) in the axial plane; and (b) a large calculus in the neck of the gallbladder (white arrow) and reactive hyperaemia (black arrow) in the adjacent liver in the coronal plane.

🩺 Clinical Features

⚡ Typical: Sudden, severe RUQ pain → radiates to right shoulder/scapula.
🤮 Nausea, vomiting, anorexia, fever.
🖐️ Murphy’s Sign: Arrest of inspiration on RUQ palpation → highly suggestive.
🟡 Jaundice: Consider CBD stone or cholangitis.

🔎 Investigations

🧪 Bloods: Leukocytosis, ↑ CRP, mildly deranged LFTs. ↑ bilirubin = CBD involvement.
🖥️ USS: 1st-line → gallstones, wall thickening, pericholecystic fluid, sonographic Murphy’s sign.
🩻 CT: For complications (abscess, perforation).
💿 MRCP: Best for CBD stones.
🛠️ ERCP: Diagnostic + therapeutic → CBD stone extraction.

📐 Calot’s Triangle: Bound by cystic duct, common hepatic duct, cystic artery. Must be clearly identified during laparoscopic cholecystectomy to avoid bile duct injury.

🚨 Complications of cholecystitis (and key gallstone-related complications)

Complication	Presentation	Management
🧴 Gallbladder empyema	Toxic “cholecystitis-plus”: persistent RUQ pain, high fever/rigors Sepsis, marked RUQ tenderness/guarding	Sepsis 6: IV fluids, blood cultures, IV antibiotics, lactate Urgent surgical source control: urgent cholecystectomy if fit If high risk/unfit → percutaneous cholecystostomy + antibiotics
🦴 Gangrenous cholecystitis	Severe, persistent RUQ pain; systemic toxicity May deteriorate rapidly; higher perforation risk	Resuscitate + IV antibiotics Urgent cholecystectomy (often difficult; low threshold for senior/HPB input)
💥 Emphysematous cholecystitis (gas-formers; ↑risk in diabetes)	Can look deceptively mild early, then sudden sepsis Severe pain, tachycardia/hypotension; crepitus not required	Immediate resuscitation + broad IV antibiotics Urgent cholecystectomy; if too unstable/high risk → cholecystostomy
🕳️ Perforation → bile peritonitis / local abscess	Sudden worsening pain, peritonism, sepsis Or subacute RUQ mass/fever (pericholecystic abscess)	Sepsis management + IV antibiotics Urgent surgery for generalised peritonitis; consider percutaneous drainage if localised abscess
🧫 Pericholecystic collection / abscess	Persistent fever and RUQ pain despite antibiotics Palpable RUQ mass possible	IV antibiotics Image-guided drainage ± delayed cholecystectomy once inflammation settles
🟡 Choledocholithiasis (CBD stone) ± obstructive jaundice	Jaundice, dark urine, pale stools, pruritus ± RUQ pain May be intermittent (“ball-valve” obstruction)	Risk stratify (LFTs/US ± MRCP/EUS) ERCP stone extraction when indicated Cholecystectomy to prevent recurrence (timing per local pathway)
🚑 Ascending cholangitis (infected obstructed biliary tree)	Charcot triad: fever, RUQ pain, jaundice Reynolds pentad: + hypotension + confusion (septic shock)	Sepsis 6 + IV antibiotics urgently Urgent biliary decompression (usually ERCP; PTC if ERCP not possible)
🫀 Gallstone pancreatitis	Severe epigastric pain → back, vomiting ± jaundice if persistent obstruction	Supportive: fluids, analgesia, oxygen, early enteral nutrition ERCP urgent if cholangitis or ongoing biliary obstruction Cholecystectomy during index admission for mild disease where feasible
🔒 Mirizzi syndrome (impacted stone compressing CHD/CBD)	Obstructive jaundice ± RUQ pain Can mimic malignancy	Specialist imaging (often MRCP) and HPB/senior surgical management Definitive surgery (higher bile duct injury risk)
🔁 Cholecystoenteric fistula → gallstone ileus	Older patient with small bowel obstruction: vomiting, distension, constipation May be intermittent then complete obstruction	Resuscitate, NG tube, correct electrolytes Urgent surgery: enterolithotomy ± staged cholecystectomy/fistula repair
🎯 Gallbladder carcinoma (rare; chronic stone disease risk)	Persistent RUQ pain, weight loss, anorexia, jaundice Sometimes incidental on histology post-cholecystectomy	Urgent referral if suspected; CT staging HPB MDT for definitive management

🎭 Differentials

Peptic ulcer disease, liver abscess
Acute pancreatitis
MI (atypical epigastric pain), pneumonia (referred pain)

💊 Management

💉 Analgesia (e.g. IV morphine), NBM.
🧪 IV antibiotics (cefuroxime + metronidazole / per protocol).
🔪 Laparoscopic cholecystectomy = definitive treatment (within 5 days ideally).
⏳ Delayed cholecystectomy (≈6 wks) if high-risk or unstable.
🛠️ ERCP for CBD stones before surgery.

📚 References

Case – Acute cholecystitis

A 46-year-old woman presents with right upper quadrant pain radiating to the back, fever, and nausea after a fatty meal. She is tender with a positive Murphy’s sign; WBC and CRP are raised, LFTs largely normal or mildly cholestatic. Bedside US shows gallstones, gallbladder wall thickening, and pericholecystic fluid. Diagnose acute calculous cholecystitis. Manage with ABCDE, IV fluids, analgesia, keep NBM, and start IV antibiotics per local policy (e.g., co-amoxiclav or cefuroxime + metronidazole in penicillin allergy). Plan early laparoscopic cholecystectomy (ideally within 24–72 h); if unfit or severe sepsis, consider percutaneous cholecystostomy. Watch for complications: empyema, gangrene/perforation, and bile duct stones; differentials include biliary colic, ascending cholangitis (fever, jaundice), and gallstone pancreatitis (↑amylase/lipase).

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Cholecystitis