Synopsis
Diagnose inflamed gallbladder disease early, identify gangrene, perforation and sepsis, provide safe initial hospital care and secure definitive or temporising source control.
- 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.
- Emphysematous change, gangrene, perforation, abscess, bile peritonitis or uncontrolled sepsis converts an urgent admission into a time-critical source-control problem.
Key red flags
Peritonism, a palpable mass, escalating pain, ileus, worsening acidosis or gas in the gallbladder wall suggests empyema, gangrene, emphysematous infection or perforation.
New confusion, low blood pressure, tachypnoea, hypoxaemia, oliguria or rising lactate indicates organ dysfunction and demands immediate sepsis treatment alongside source-control planning.
Unexplained fever, cholestasis or abdominal deterioration in intensive care, major trauma, burns or postoperative illness should prompt imaging even without stones or reliable tenderness.
Investigation priorities
Grade physiological disturbance immediately and identify a patient who needs resuscitation before diagnostic refinement.
Management branches
Sustained focal pain, inflammation and imaging or examination support acute cholecystitis.
- Assess ABCDE, establish venous access, prescribe analgesia and antiemetic therapy, and replace fluid according to perfusion and comorbidity.
- Send blood tests, cultures when indicated and urgent ultrasound, while involving the on-call surgical team at the start of care.
- Start an antimicrobial regimen from the current local biliary-infection guideline when infection is suspected, adjusting for allergy, renal function and prior microbiology.
- Plan early laparoscopic cholecystectomy within the NICE one-week window when the person is an appropriate operative candidate.