Acute & Chronic Cholecystitis
Gallbladder Inflammation — Causes, Diagnosis & Surgical Treatment
Overview
Cholecystitis is inflammation of the gallbladder. It most commonly results from a gallstone obstructing the cystic duct — the tube connecting the gallbladder to the common bile duct — causing bile to accumulate, the gallbladder wall to become inflamed, and eventually, bacterial infection to develop. Acute cholecystitis is one of the most common surgical emergencies in India, accounting for a significant proportion of emergency hospital admissions.
Acute cholecystitis occurs in approximately 20% of patients with symptomatic gallstones. It is the most common complication of gallstone disease, affecting an estimated 200,000 patients annually in India. Women are more commonly affected than men, reflecting the higher prevalence of gallstones in women. Acalculous cholecystitis (without stones) accounts for 5–10% of cases and is associated with critical illness, trauma, and prolonged fasting.
Types
Acute Calculous Cholecystitis
90–95% of acute cholecystitis casesThe most common type — caused by a gallstone obstructing the cystic duct. Bile accumulates in the gallbladder, causing distension, ischaemia of the gallbladder wall, and bacterial superinfection. Requires urgent hospitalisation and cholecystectomy.
Acute Acalculous Cholecystitis
5–10% of acute cholecystitis casesGallbladder inflammation without stones, occurring in critically ill patients (ICU, post-major surgery, trauma, burns, sepsis). Caused by gallbladder ischaemia and bile stasis. Higher risk of perforation and gangrene than calculous cholecystitis. Managed with percutaneous cholecystostomy or surgery.
Chronic Cholecystitis
Most patients with symptomatic gallstonesRepeated episodes of biliary colic and low-grade inflammation cause progressive scarring and thickening of the gallbladder wall. The gallbladder becomes fibrotic and dysfunctional. Presents as recurrent right upper quadrant pain and indigestion. Treated with elective laparoscopic cholecystectomy.
Causes & Risk Factors
Cystic Duct Obstruction by Gallstone
The most common cause. A gallstone impacts in the cystic duct, obstructing bile outflow. Bile accumulates, the gallbladder distends, and the wall becomes ischaemic. Bacterial superinfection (E. coli, Klebsiella, Enterococcus) follows in most cases, converting chemical inflammation to infective cholecystitis.
Gallbladder Ischaemia
In acalculous cholecystitis, reduced blood flow to the gallbladder (from hypotension, vasopressors, or systemic illness) causes ischaemic injury to the gallbladder wall. Concentrated bile in a poorly contracting gallbladder exacerbates the injury.
Biliary Sludge
Thick, viscous bile (biliary sludge) can obstruct the cystic duct in the absence of discrete stones, causing cholecystitis. Sludge is common in pregnancy, prolonged fasting, and total parenteral nutrition.
Parasitic Infection
In endemic areas, parasites such as Ascaris lumbricoides can migrate into the biliary tract and cause cholecystitis. Less common in urban India but important in rural populations.
Signs & Symptoms
Right Upper Quadrant Pain
Severe, constant pain in the upper right abdomen, typically more persistent than biliary colic (lasting >6 hours). The pain is caused by gallbladder distension and inflammation. It may radiate to the right shoulder or back (referred pain via the phrenic nerve).
Murphy's Sign
A clinical sign elicited on examination — the patient involuntarily stops inhaling when the examiner presses on the right upper quadrant. Caused by the inflamed gallbladder descending onto the examiner's fingers during inspiration. Highly specific for acute cholecystitis.
Fever and Chills
Fever (typically 38–39°C) with chills indicates bacterial infection of the gallbladder. High fever (>39°C) with rigors suggests more severe infection or the development of complications (empyema, perforation).
Nausea and Vomiting
Accompanies pain in most patients. Persistent vomiting with inability to keep fluids down requires IV fluid replacement.
Localised Abdominal Tenderness
Tenderness and guarding in the right upper quadrant. Generalised peritonism (board-like rigidity) suggests gallbladder perforation — a surgical emergency.
Jaundice (in some cases)
Mild jaundice may occur due to oedema of the common bile duct from adjacent gallbladder inflammation (Mirizzi syndrome) or from a co-existing CBD stone. Significant jaundice should prompt MRCP to exclude CBD obstruction.
Diagnosis
Ultrasound Abdomen
85–90% sensitivityFirst-line investigation. Key findings: gallstones, gallbladder wall thickening (>4 mm), pericholecystic fluid, sonographic Murphy's sign (tenderness with probe pressure over gallbladder). Sensitivity for acute cholecystitis is 85–90%.
Full Blood Count (FBC)
Elevated in 85% of acute cholecystitisElevated white cell count (leucocytosis) with neutrophilia confirms infection. Very high WBC (>20,000) suggests severe infection, empyema, or perforation.
C-Reactive Protein (CRP)
Elevated in most cases; correlates with severityElevated CRP (>75 mg/L) is a marker of significant inflammation and infection. Used to grade severity of cholecystitis (Tokyo Guidelines) and guide treatment decisions.
CT Scan Abdomen
90–95% for complicationsUsed when ultrasound is inconclusive or complications are suspected. CT can detect gallbladder wall thickening, pericholecystic fat stranding, emphysematous cholecystitis (gas in gallbladder wall — surgical emergency), and perforation.
HIDA Scan
97% sensitivity for acute cholecystitisNuclear medicine scan showing non-filling of the gallbladder (due to cystic duct obstruction) confirms acute cholecystitis. Used when ultrasound is equivocal. Sensitivity 97%, specificity 90%.
Liver Function Tests
Mildly elevated in 25% of casesMildly elevated bilirubin and ALP may occur due to adjacent inflammation. Significantly elevated bilirubin should prompt MRCP to exclude CBD stones.
Potential Complications
If left untreated, gallstone disease can progress to the following complications:
- Gallbladder empyema — pus-filled gallbladder requiring urgent cholecystectomy or percutaneous drainage
- Gangrenous cholecystitis — ischaemic necrosis of the gallbladder wall, predisposing to perforation
- Gallbladder perforation — bile peritonitis or localised abscess formation
- Emphysematous cholecystitis — gas-forming organisms infect the gallbladder wall; high mortality without urgent surgery
- Cholecystoenteric fistula — gallbladder erodes into adjacent bowel (duodenum, colon)
- Gallstone ileus — large stone passes through fistula into bowel, causing small bowel obstruction
- Mirizzi syndrome — impacted stone in cystic duct compresses the common hepatic duct, causing jaundice
Treatment Options
Early Laparoscopic Cholecystectomy (within 72 hours)
The gold-standard treatment for acute cholecystitis. Surgery within 72 hours of symptom onset is associated with shorter hospital stay, lower complication rate, and lower conversion rate to open surgery compared to delayed surgery. Supported by Tokyo Guidelines and multiple randomised controlled trials.
Suitable for: All patients fit for surgery presenting within 72 hours
Interval Cholecystectomy (6–8 weeks later)
In patients presenting late (>72 hours) with a palpable mass (pericolecystic abscess), conservative management with antibiotics followed by elective cholecystectomy 6–8 weeks later may be safer. However, this approach carries a 20–30% risk of recurrent cholecystitis before surgery.
Suitable for: Late-presenting patients with pericolecystic abscess or mass
IV Antibiotics
All patients with acute cholecystitis receive IV antibiotics covering gram-negative organisms and anaerobes (typically piperacillin-tazobactam or cefuroxime + metronidazole). Antibiotics control infection but do not treat the underlying stone obstruction — surgery remains necessary.
Suitable for: All patients as adjunct to surgical treatment
Percutaneous Cholecystostomy
In patients too unwell for surgery (severe sepsis, multi-organ failure), a drain can be placed into the gallbladder under ultrasound guidance to decompress it. This is a temporising measure — definitive cholecystectomy is planned when the patient recovers.
Suitable for: Critically ill patients unfit for immediate surgery
Prevention
- Early cholecystectomy for symptomatic gallstones before acute cholecystitis develops
- Avoid prolonged fasting — eat regular meals to stimulate gallbladder contraction
- Maintain a healthy weight to reduce gallstone formation risk
- Seek medical attention promptly for biliary colic — do not ignore recurring episodes
- Regular follow-up after a first episode of cholecystitis if surgery is deferred
When to Seek Immediate Medical Help
- Severe right upper quadrant pain lasting more than 6 hours
- Fever above 38°C with abdominal pain
- Jaundice developing alongside abdominal pain
- Generalised abdominal rigidity (board-like abdomen) — suggests perforation
- Confusion, low blood pressure, or rapid heart rate with fever — signs of sepsis
Prognosis & Outlook
With prompt diagnosis and early laparoscopic cholecystectomy, the prognosis for acute cholecystitis is excellent. Mortality from uncomplicated acute cholecystitis is under 0.5% in fit patients. Delayed treatment or complications (perforation, empyema, emphysematous cholecystitis) significantly worsen outcomes. Chronic cholecystitis is completely cured by cholecystectomy, with over 95% of patients symptom-free after surgery.
Frequently Asked Questions
What is the difference between biliary colic and acute cholecystitis?
Biliary colic is caused by a gallstone temporarily obstructing the cystic duct — the pain lasts 1–6 hours and resolves when the stone shifts. Acute cholecystitis occurs when the stone remains impacted, causing persistent gallbladder inflammation, fever, and tenderness. Cholecystitis pain lasts more than 6 hours and is associated with fever and localised tenderness (Murphy's sign).
How quickly do I need surgery for acute cholecystitis?
Early surgery (within 72 hours of symptom onset) is the gold standard. Multiple studies show that early cholecystectomy is safer, faster, and associated with shorter hospital stay than delayed surgery. If you are diagnosed with acute cholecystitis, do not delay — contact Dr. Patil immediately.
Can acute cholecystitis be treated with antibiotics alone?
Antibiotics control infection but do not remove the obstructing stone or treat the underlying cause. Without cholecystectomy, acute cholecystitis recurs in 20–30% of patients within 6 months. Antibiotics are used as an adjunct to surgery, not as a substitute.
Is laparoscopic surgery possible for acute cholecystitis?
Yes. Laparoscopic cholecystectomy is the preferred approach even for acute cholecystitis. The conversion rate to open surgery is higher (10–15%) than for elective cases due to inflammation and adhesions, but experienced surgeons like Dr. Patil complete the majority of acute cholecystitis cases laparoscopically.
MS (General Surgery) · Fellowship in Advanced Laparoscopy & Bariatric Surgery (Belgium) · Consultant Surgeon, Apollo Clinic Indiranagar
Last reviewed: April 2026 · View credentials
This content has been reviewed for medical accuracy by a qualified consultant surgeon with over 12 years of experience in advanced laparoscopic and robotic surgery. It is intended for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment.