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← Gastroenterology and hepatology indexChapter sections
OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Acute cholecystitis

Gastroenterology and hepatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Time-critical presentation

Hypotension, confusion, tachypnoea, hypoxaemia, oliguria, rising lactate, peritonism, escalating pain, ileus or gas in the gallbladder wall suggests sepsis, empyema, gangrene, emphysematous infection or perforation. Begin immediate resuscitation and antimicrobial treatment and obtain urgent senior surgical and source-control review.

Overview

Diagnose inflamed gallbladder disease early, identify gangrene, perforation and sepsis, provide safe initial hospital care and secure definitive or temporising source control.

Sustained obstruction of the cystic duct causes gallbladder distension, chemical inflammation and sometimes secondary bacterial infection. Calculous disease predominates, but acalculous cholecystitis occurs in critically ill, postoperative, traumatised or severely immunocompromised patients and can progress with deceptively few abdominal signs. Older adults may present through delirium, anorexia or functional decline rather than a textbook pain history.

Diagnosis integrates time course, examination, inflammation and imaging. Right-upper-quadrant pain lasting beyond several hours with fever and Murphy tenderness is typical. Ultrasound can show a stone impacted at the neck, a thickened wall, distension or surrounding fluid, but wall oedema also occurs with heart failure, hypoalbuminaemia and hepatitis. If clinical probability remains high after an equivocal study, senior radiology and surgical teams select repeat ultrasound, radionuclide imaging, CT or MRCP according to the diagnostic question.

Management has two linked goals: stabilise acute illness and remove the diseased gallbladder. Early laparoscopic cholecystectomy during the index period reduces recurrence and is the NICE standard for suitable patients. Antibiotics support care when infection is plausible but

Aetiology

01

Gallstone obstruction

Persistent cystic-duct obstruction by a gallstone is the usual trigger, converting transient biliary pain into sustained gallbladder inflammation.

02

Acalculous disease

Critical illness, trauma, major surgery, prolonged fasting or impaired perfusion can cause gallbladder stasis and ischaemic inflammation without visible stones.

03

Secondary infection

Bacterial infection may complicate an obstructed or ischaemic gallbladder, particularly when inflammation progresses to empyema, gangrene or systemic sepsis.

Pathophysiology

  1. 1
    Cystic-duct occlusion

    Continued bile secretion behind an impacted stone raises intraluminal pressure and causes gallbladder distension, initiating local inflammatory injury.

  2. 2
    Mural inflammation

    Pressure, chemical irritation and impaired venous or lymphatic drainage produce wall oedema, local tenderness and surrounding inflammatory fluid.

  3. 3
    Ischaemic progression

    Persistent pressure and infection can compromise arterial supply, leading to necrosis, perforation and generalised or localised peritoneal contamination.

Clinical features and red flags

Typical calculous disease

Constant right-upper-quadrant or epigastric pain, local guarding, fever, nausea and raised inflammatory markers follow a prior history that may include shorter biliary attacks.

Complicated gallbladderRed flag

Peritonism, a palpable mass, escalating pain, ileus, worsening acidosis or gas in the gallbladder wall suggests empyema, gangrene, emphysematous infection or perforation.

Septic physiologyRed flag

New confusion, low blood pressure, tachypnoea, hypoxaemia, oliguria or rising lactate indicates organ dysfunction and demands immediate sepsis treatment alongside source-control planning.

Acalculous phenotypeRed flag

Unexplained fever, cholestasis or abdominal deterioration in intensive care, major trauma, burns or postoperative illness should prompt imaging even without stones or reliable tenderness.

Duct complication

Jaundice, marked cholestasis or duct dilatation is not explained by isolated cystic-duct disease; assess for choledocholithiasis, Mirizzi syndrome or ascending cholangitis.

Investigations

  1. 01
    Bedside observations and lactateFirst step
    Why
    Grade physiological disturbance immediately and identify a patient who needs resuscitation before diagnostic refinement.
    Interpretation and limitations
    A normal early lactate does not exclude local gangrene, while hypotension, altered mentation or impaired oxygenation indicates high-risk illness regardless of imaging delay.
  2. 02
    FBC, CRP and renal profile
    Why
    Quantify inflammation, establish renal function and guide fluid, contrast, antibiotic and operative decisions.
    Interpretation and limitations
    Neutrophilia and rising CRP support active inflammation but may be blunted by immunosuppression; acute kidney injury increases severity and changes medicine dosing.
  3. 03
    Liver profile and coagulation
    Why
    Look for associated duct obstruction or hepatic dysfunction and prepare safely for intervention.
    Interpretation and limitations
    Mild enzyme change can accompany inflammation, but substantial bilirubin or alkaline phosphatase elevation should trigger dedicated duct assessment rather than being dismissed.
  4. 04
    Right-upper-quadrant ultrasound
    Why
    Confirm stones and assess gallbladder wall, distension, pericholecystic fluid, focal tenderness and bile-duct calibre.
    Interpretation and limitations
    A coherent cluster supports cholecystitis. Wall thickening alone is non-specific, and a technically limited negative examination cannot safely override a strong clinical picture.

Differential diagnosis

01

Biliary colic

Pain resolves as transient obstruction passes and there is no sustained fever, focal peritonism or inflammatory response typical of cholecystitis.

02

Ascending cholangitis

Jaundice, rigors, cholestatic blood tests and common-duct obstruction favour infected biliary-tree obstruction rather than isolated gallbladder inflammation.

03

Pancreatitis or peptic disease

Back-radiating epigastric pain with raised pancreatic enzymes suggests pancreatitis; free gas, bleeding or endoscopic ulceration points towards peptic pathology.

Management

01AdmissionInitial hospital treatmentFirst stepSustained focal pain, inflammation and imaging or examination support acute cholecystitis.+
  1. 1Assess ABCDE, establish venous access, prescribe analgesia and antiemetic therapy, and replace fluid according to perfusion and comorbidity.
  2. 2Send blood tests, cultures when indicated and urgent ultrasound, while involving the on-call surgical team at the start of care.
  3. 3Start an antimicrobial regimen from the current local biliary-infection guideline when infection is suspected, adjusting for allergy, renal function and prior microbiology.
  4. 4Plan early laparoscopic cholecystectomy within the NICE one-week window when the person is an appropriate operative candidate.
02DeteriorationSepsis or perforation responseOrgan dysfunction, peritonism, gas, collection or worsening physiology suggests complicated disease.+

Complications

01

Gangrene and perforation

Mural ischaemia can progress to necrosis and rupture, producing pericholecystic abscess, bile peritonitis or fistulation into adjacent bowel.

02

Empyema and sepsis

Infected gallbladder contents may cause bacteraemia, hypotension, kidney injury and multiorgan dysfunction, particularly in older or immunosuppressed people.

03

Biliary fistula and obstruction

Chronic inflammation may erode into bowel; a large migrated stone can obstruct distally, while local inflammation can compress the common hepatic duct.

Monitoring and follow-up

  • Trend temperature, pulse, blood pressure, respiratory status, urine output, cognition and pain rather than relying on a single early score.
  • Repeat renal function, liver profile, CRP and lactate at a frequency matched to illness severity and resuscitation.
  • Review culture results and operative findings daily so broad antibiotics are narrowed and stopped at an appropriate source-controlled endpoint.
  • After cholecystostomy, document drain position, output, flushing instructions, complications and the named team responsible for removal or exchange.
  • At discharge, record timing of cholecystectomy or follow-up, recurrence safety-netting and any unresolved common-duct investigation.

Special situations

Murphy can disappear

Analgesia, neuropathy, frailty or gallbladder necrosis may reduce focal tenderness, so a negative sign cannot neutralise systemic deterioration.

Wall thickening has mimics

Heart failure, ascites, hepatitis and low albumin can oedematise the gallbladder wall without primary cholecystitis.

Acalculous disease is dangerous

Critical illness impairs examination and ultrasound transport; unexplained sepsis may be the only clue until necrosis is advanced.

Antibiotics are supportive

Clinical improvement on antimicrobials does not erase the recurrence risk from a persistently stone-bearing gallbladder.

A drain is a bridge

Percutaneous treatment creates a new device-care problem and should be paired with later fitness reassessment and ownership.

Common pitfalls

  1. 01

    Waiting for ultrasound before resuscitating a patient with septic physiology.

  2. 02

    Excluding cholecystitis because Murphy tenderness is absent after analgesia.

  3. 03

    Calling marked cholestasis an expected feature without checking the common duct.

  4. 04

    Using antibiotics as a permanent alternative to source-control assessment.

  5. 05

    Choosing cholecystostomy on age alone without anaesthetic and surgical review.

  6. 06

    Discharging a drain without named follow-up and removal responsibility.

Practice

Two practice questions

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Question 1 of 2
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Gastroenterology and hepatologyOriginal SBA

Timing of definitive surgery

An otherwise fit patient has ultrasound-confirmed acute calculous cholecystitis and improves after initial hospital treatment. According to NICE CG188, what definitive timing should be offered?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG188 gallstone disease recommendations
  • NICE QS104 acute cholecystitis quality statement
  • NICE CKS acute cholecystitis
  • BNF gastrointestinal antibacterial therapy

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
do not
release an obstructed, necrotic or perforated organ. Frailty, pregnancy, antithrombotic therapy and critical illness require multidisciplinary planning rather than an automatic permanent drain strategy.

Key points

  • Acute cholecystitis usually follows persistent cystic-duct obstruction and presents with sustained right-upper-quadrant pain, fever, focal tenderness and inflammatory-marker elevation rather than a completely resolving attack.
  • A Murphy sign supports the diagnosis but is less reliable after analgesia, in older or immunosuppressed people, and in severe disease with gallbladder necrosis.
  • Ultrasound is first-line: seek stones, gallbladder distension, wall thickening, pericholecystic fluid and a sonographic Murphy sign while remembering that no single feature is diagnostic alone.
  • Apply ABCDE and sepsis assessment before imaging when the patient is unstable; hypotension, confusion, hypoxaemia, oliguria, lactate elevation or peritonism requires senior surgical and critical-care escalation.
  • Give analgesia, appropriate crystalloid for hypovolaemia, antiemetic treatment and local-guideline antibiotics when infection is suspected; obtain cultures first only if this causes no delay.
  • NICE advises early laparoscopic cholecystectomy within one week of diagnosis when surgery is appropriate, rather than routine cooling-off and delayed readmission.
  • Percutaneous cholecystostomy is not a default substitute for surgery: NICE reserves it for people in whom surgery is contraindicated and conservative management is unsuccessful.
  • 05
    Contrast CT abdomen
    Why
    Define perforation, abscess, emphysematous or gangrenous change and alternative pathology when disease is severe or ultrasound is inconclusive.
    Interpretation and limitations
    CT is especially useful for complications but may miss small calculi; contrast and radiation choices must reflect urgency, renal context and pregnancy.
  • 06
    Blood cultures
    Why
    Identify bacteraemia and permit antibiotic narrowing in febrile or septic presentations.
    Interpretation and limitations
    Collect separate sets before antibiotics when feasible, but negative cultures do not exclude a gallbladder source and sampling must never postpone treatment.
    • 1
    Activate the local sepsis pathway, involve senior surgery, anaesthesia and critical care, and monitor response to resuscitation continuously.
  • 2Obtain urgent complication-focused imaging only if it will not delay necessary operative or interventional source control.
  • 3Broaden antimicrobial cover according to the trust guideline and previous resistant organisms, then narrow when cultures and operative findings permit.
  • 4Choose urgent cholecystectomy, drainage or another intervention through senior multidisciplinary assessment of anatomy and physiological reserve.
    • 03High riskWhen surgery is contraindicatedAnaesthetic and surgical review concludes that immediate cholecystectomy carries unacceptable risk and conservative treatment is failing.+
    1. 1Correct reversible physiological problems and clarify whether the contraindication is temporary, because age alone is not an adequate decision rule.
    2. 2Discuss image-guided percutaneous cholecystostomy with surgery and interventional radiology under the NICE criteria, including bleeding and drain risks.
    3. 3Continue sepsis therapy and confirm clinical plus biochemical response after drainage; re-image early if output or improvement is inadequate.
    4. 4Reconsider laparoscopic cholecystectomy once fitness improves and provide explicit drain care, exchange or removal ownership before discharge.
    Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
    Treats suspected bacterial infection while definitive gallbladder source control is arranged and microbiology is clarified.

    Local biliary-infection antibiotic regimen

    Select intravenous agents, dose interval and duration from the current trust guideline and BNF after allergy and renal review.

    Do not copy a universal combination: resistance, previous cultures, recent healthcare exposure, renal injury and severe beta-lactam allergy materially change selection.

    Controls severe inflammatory pain during resuscitation, imaging and preparation for definitive intervention.

    Parenteral opioid analgesia

    Give small intravenous or subcutaneous increments under the local acute-pain protocol, reassessing pain, consciousness and respiratory rate after each dose.

    Reduce and space doses in frailty, sleep-disordered breathing, hepatic or renal impairment; vomiting and sedation can complicate assessment and consent.

    Improves comfort and helps correct dehydration caused by nausea or repeated vomiting.

    Antiemetic therapy

    Choose a current BNF adult regimen based on QT interval, Parkinsonism risk, bowel obstruction concern and the intended route.

    Avoid stacking QT-prolonging or dopamine-blocking agents; an antiemetic response does not make ongoing obstruction or peritonitis safe.

    Emphysematous change, gangrene, perforation, abscess, bile peritonitis or uncontrolled sepsis converts an urgent admission into a time-critical source-control problem.