ACUTE CHOLECYSTITIS

✓ Medically ReviewedDISEASEID: MDBT0112🚨 TRIAGE: URGENTICD-10: K81.0

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Definition

CLINICAL DEFINITION

Acute cholecystitis is sudden inflammation of the gallbladder (bile-storing sac under the liver). It usually follows cystic duct (gallbladder outlet tube) blockage by a gallstone (hardened bile lump). Trapped bile raises pressure inside the sac. Venous congestion (blocked blood outflow) causes wall swelling with ischaemia (low blood flow). Bacterial overgrowth then drives infection. Diagnosis needs local signs plus systemic inflammation plus imaging per Tokyo Guidelines.

IN PLAIN ENGLISH

Gallbladder is a small sac. It stores bile to digest fat. A stone can block its outlet. Blocked bile causes pain and fever. It needs scans and prompt care.

COMMON MISCONCEPTION / WHAT IT DOES NOT MEAN

Acute cholecystitis is not biliary colic (brief stone pain without fever or inflammation). It is not chronic cholecystitis (long-standing wall thickening with recurrent mild pain). It is not choledocholithiasis (stones in the common bile duct, the main bile channel). It is not cholangitis (bile duct infection with jaundice, yellow skin, and sepsis). It is not ulcer disease or hepatitis without gallbladder inflammation.

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Word Breakdown

chole-

=bile

cyst

=sac or bladder, here the gallbladder

-itis

=inflammation

Literal Meaning: sudden inflammation of the bile sac

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Abbreviations

AC=Acute cholecystitis - sudden gallbladder inflammation

RUQ=Right upper quadrant - upper right belly area under the ribs

WBC=White blood cells - infection-fighting cells raised in inflammation

TG18=Tokyo Guidelines 2018 - diagnostic and severity rules for biliary infection

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Synonyms & Variants

Acute gallbladder inflammation›Acute calculous cholecystitis›Acute acalculous cholecystitis›

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Category-Specific Context

Acute cholecystitis is a Disease because it is a distinct inflammatory process with tissue injury and course. It is not a Symptom (felt complaint) such as belly pain alone. It is not a single Sign (exam finding) such as Murphy sign (pain on pressed gallbladder) alone. It spans stone-related and stone-free origins (blockage levels). Care targets drainage with infection control rather than pain relief alone.

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Clinical Context & Usage

CLINICAL SETTINGS

Emergency DepartmentAcute Surgical UnitRadiology and Ultrasound UnitIntensive Care Unit for Severe CasesSurgical Follow-up Clinic

USAGE & DOCUMENTATION NOTES

Use acute cholecystitis only when inflammation meets clinical, laboratory and imaging criteria. Specify calculous (stone-related) versus acalculous (without stones) whenever known. Record Tokyo diagnostic criteria with severity grade in the note. Document duct assessment with liver tests (bile backup labs) to exclude concurrent duct stones. Avoid cholecystitis alone when acuity and cause are known.

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Primary Causes & Pathophysiology

PATHOPHYSIOLOGY

Gallstone impaction in the neck or cystic duct (outlet tube) blocks bile outflow. Rising pressure inside the sac impairs venous and lymphatic drainage (fluid outflow). Wall distension causes ischaemia (low blood flow) with mucosal (inner lining) injury. Phospholipase (fat-digesting chemicals) with prostaglandins (pain and fever signals) plus bacterial overgrowth amplify inflammation. Without relief, necrosis (tissue death) with empyema (pus-filled sac), gangrene or perforation can develop.

PRIMARY CAUSES

Gallstone impaction in cystic duct or gallbladder neck

Obstructs bile outflow causing stasis (stagnant bile) with distension, low blood flow and secondary bacterial infection

Biliary sludge and microlithiasis

Thick bile with cholesterol crystals and microstones blocks the outlet and triggers the same pressure and ischaemia cascade

Acute acalculous ischaemia in critical illness

Low pressure, prolonged fasting, vein feeding and ventilation reduce perfusion (blood supply) and motility causing stasis without stones

Mirizzi syndrome with cystic duct compression

Impacted neck stone compresses the adjacent hepatic duct (liver bile tube) causing obstruction with gallbladder inflammation

Cystic duct stricture, fibrosis or mass obstruction

Benign scarring or tumour narrows the outlet tube and prevents emptying with pressure injury and infection

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Drug-Induced Causes

💊 Ceftriaxone ↗

Mechanism: Calcium-ceftriaxone precipitation forms sludge and pseudolithiasis (reversible stone-like material) that can obstruct the outlet

→ Stop ceftriaxone when feasible, hydrate, repeat ultrasound to confirm resolution, give antibiotics with surgical review if true inflammation persists

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Epidemiology

Prevalence:Gallstones affect about 10 to 15 percent of adults in Western populations. Acute cholecystitis is the commonest inflammatory complication leading to emergency gallbladder removal. It accounts for a large share of emergency visits for upper belly pain. Risk rises with age, obesity, rapid weight loss and prolonged fasting.

Age Group:It mainly affects adults with incidence rising with age. Peak occurs in middle-aged and older adults with gallstones. It is uncommon in children except with haemolytic disease (red cell breakdown), critical illness or prolonged vein feeding.

Geographic Distribution:Acute cholecystitis occurs worldwide wherever gallstones occur. Patterns follow cholesterol stone burden with diet change, obesity and ageing. Detection tracks ultrasound and surgical access. No climate restriction applies.

Red Flags & Triage ★

TRIAGE LEVEL

🚨 URGENT

DO NOT MISS — LIFE-THREATENING PRESENTATIONS

Gallbladder perforation with biliary peritonitis
Acute cholangitis with sepsis
Gangrenous and emphysematous cholecystitis
Septic shock with organ failure
Common bile duct stones with obstruction

URGENT EVALUATION TRIGGERS

Right upper pain beyond 6 hours with fever
Positive Murphy sign with high white cells
Low pressure, fast pulse or confusion suggesting sepsis
Jaundice with vomiting and severe belly pain
Guarding, rebound or rigid abdomen suggesting perforation
Imaging with wall thickening, fluid around the sac or gas

Contraindications & Precautions

CONTRAINDICATIONS

Do not manage gangrenous, emphysematous or perforated disease with antibiotics alone without surgical evaluation
Do not perform immediate removal without fitness review in severe Grade III disease with organ failure
Do not prolong fasting without fluid and salt monitoring

SPECIAL PRECAUTIONS

Watch closely for sepsis in elderly, diabetic and immunocompromised patients
Correct fluids and salts during fasting with vomiting illness
Recheck pain, fever, Murphy sign and guarding often
Arrange early anaesthesia and surgical review for operative planning

Complications

DOWNSTREAM CLINICAL COMPLICATIONS

Gangrenous cholecystitis with wall necrosis (tissue death)
Gallbladder empyema with pus accumulation
Gallbladder perforation with bile peritonitis (belly lining infection)
Pericholecystic abscess formation
Cholecystoenteric fistula with gallstone ileus (gut blockage)
Sepsis and septic shock
Mirizzi syndrome with biliary obstruction

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Confused With (LASA & DDx) ★

LEXICAL (LASA) — SIMILAR NAMES

Cholangitis

Confused by shared fever with right upper pain, but it is bile duct infection with jaundice and sepsis, not gallbladder inflammation

Cholelithiasis

Shares gall prefix but means gallstones without inflammation, often painless or with brief colic only

Choledocholithiasis

Similar spelling with biliary pain but means stones in the common bile duct (main channel), often with jaundice and pancreas risk

Chronic cholecystitis

Shares root words with different acuity but means long-standing low-grade inflammation with fibrosis, not sudden infection

CLINICAL DIFFERENTIAL DIAGNOSES (DDx)

Biliary colic

Key Distinguishing Feature: Brief episodic pain under 6 hours without fever, high white cells or wall thickening

Acute cholangitis

Key Distinguishing Feature: Fever with jaundice and right upper pain plus bile duct dilation with sepsis

Choledocholithiasis

Key Distinguishing Feature: Jaundice with high bilirubin and dilated common duct without gallbladder wall inflammation

Acute pancreatitis

Key Distinguishing Feature: Upper belly pain radiating to the back with markedly raised lipase and pancreatic swelling

Peptic ulcer perforation

Key Distinguishing Feature: Sudden severe upper pain with free air under the diaphragm and rigid abdomen

Acute hepatitis

Key Distinguishing Feature: Diffuse liver tenderness with markedly raised transaminases and viral prodrome (early flu-like phase)

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Clinical Pearls

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Confirm sonographic Murphy (probe pain over the sac) with wall thickening on ultrasound at diagnosis. Imaging-positive pain beyond 6 hours favours cholecystitis over colic.

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Plan early laparoscopic removal (keyhole surgery) within 72 hours for mild to moderate disease per protocol. Delay raises gangrene and perforation risk.

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Keep low threshold for imaging with surgical review in elderly and diabetic patients. Both groups can develop gangrene without fever or high white cells.

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Check liver tests with duct imaging in every case before surgery. Concurrent duct stones or cholangitis (duct infection) change drainage and antibiotic plans.

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Give fluids, antibiotics, pain relief and antiemetics (nausea drugs) while nil by mouth. Monitor sepsis signs with pressure, pulse, urine and re-exam.

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Example Usage & SOAP

CLINICAL SENTENCE

""48-year-old woman with RUQ pain, fever and Murphy sign has acute cholecystitis.""

IN A SOAP NOTE

S: 52-year-old woman with 10-hour right upper pain, fever, nausea and vomiting, no prior biliary surgery. O: Temp 38.4C, BP 128/78, HR 104, RR 18, SpO2 97 percent on air, tender right upper quadrant with positive Murphy sign and guarding. Labs show high white cells with raised CRP and bilirubin 1.8. Ultrasound shows distended sac with 5 mm wall, fluid around the sac and impacted neck stone. A: Acute calculous cholecystitis, moderate severity. P: Nil by mouth, IV fluids, antibiotics, analgesia with antiemetic, urgent surgical review for early removal, sepsis watch.

DIFFERENTIAL DIAGNOSIS CONTEXT

Right upper pain with fever and high white cells favours acute cholecystitis when wall thickening is present. Brief pain under 6 hours without inflammation favours biliary colic. Jaundice with duct dilation and sepsis favours cholangitis (duct infection). Upper pain radiating to the back with high lipase favours pancreatitis. Check liver tests, lipase and ultrasound together.

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Classifications & Scoring

GRADING SYSTEM

Tokyo Guidelines TG18 Severity Grading for Acute Cholecystitis

Grades disease as Grade I mild, Grade II moderate or Grade III severe with organ failure to guide early surgery versus drainage

SCORING TOOL

Tokyo Guidelines TG18 Diagnostic Criteria for Acute Cholecystitis

Requires one local inflammation sign plus one systemic sign plus one imaging finding; definite diagnosis needs all three domains

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Prognosis

SHORT-TERM OUTCOME

Most mild cases improve quickly with fluids, antibiotics and early gallbladder removal. Delay raises gangrene, perforation and sepsis risk. Death is low in mild disease. Elderly, diabetic and critically ill patients face higher danger.

LONG-TERM PROGNOSIS

Gallbladder removal is curative and prevents recurrence in stone-related disease. Without surgery, biliary pain or inflammation often returns within two years. Retained duct stones or stricture (narrowing) after care are uncommon with modern follow-up.

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References & Coding

ICD-10 DIAGNOSTIC CODE

K81.0

LITERATURE CITATIONS & GUIDELINES

[1]WHO ICD-10 K81.0 Acute cholecystitis

[2]Tokyo Guidelines TG18 for acute cholecystitis

[3]World Society of Emergency Surgery biliary emergency guidance

[4]Harrison's Principles of Internal Medicine biliary tract disease

MEDICAL DISCLAIMER — This content is intended for educational purposes and qualified healthcare professionals only. Always refer to current clinical diagnostic criteria, institutional protocols, and official guidelines. Medobo is not responsible for clinical decisions made based on this content.