Acute cholecystitis refers to inflammation of the gallbladder and classically presents as a syndrome of right upper quadrant pain, fever, and leucocytosis.
Gallstones are present in 7% of the population, and more common in women and with increasing age. Gallstones can cause biliary colic, acute cholecystitis and chronic cholecystitis. Approximately 20% will become symptomatic within 15 years of follow-up, 1-2% will develop other complications and the majority of these complications will occur in patients with biliary colic.
In a systematic review, cholecystitis was seen in 6-11% of patients with symptomatic gallstones over a median follow-up of 7 to 11 years. Acalculous cholecystitis is clinically identical to acute cholecystitis but is not associated with gallstones and usually occurs only in critically ill patients. It accounts for approximately 10% of cases of acute cholecystitis and is associated with high morbidity and mortality rates.
Step 1: Pathway Entry
RUQ or epigastric pain, around the waist, or to the back, scapula, or right shoulder, left upper back.
Fever may be present.
- increased age
- diabetes mellitus
- profound weight loss
- cystic fibrosis
- malabsorption syndromes
- various medication (oral contraceptive pill and clofibrate).
Step 2: Is the patient stable?
Initiate resuscitation if unstable. If the patient has severe sepsis, initiate your local sepsis pathway.
Consideration of other life threatening diagnoses - acute pancreatitis, septic shock from other intraabdominal source or right sided pneumonia, perforated viscus (in particular perforated peptic ulcer, ruptured ectopic pregnancy in women of childbearing age), cardiac ischaemia.
Step 3: Initial assessment
Detailed history and examination. Positive Murphy's sign is 97% sensitive and 48% specific.
ECG to exclude cardiac ischaemia.
Blood tests should include FBC, EUC, LFT, lipase (and blood cultures if febrile), beta-HCG in women of childbearing age.
Step 4: Imaging
AXR not useful in diagnosing gallstones (only 20% radiopaque). If done it may detect air in the biliary tract or gallbladder wall caused by emphysematous cholecystitis, cholangitis, or cholecystic-enteric fistula (however other imaging modalities are more useful).
CXR if considering possible pneumonia or perforated viscus.
- Point of care ultrasound should be used as a ‘rule in’ test and followed by formal imaging as soon as practicable.
- ACEM supports the use of ultrasound imaging by emergency physicians for biliary tract disease. Emergency physicians who perform point of care ultrasound should be credentialed.
- Biliary ultrasound is covered in our Emergency Procedures App.
Formal ultrasound (sensitivity 94%, specificity 78%).
CT (sensitivity 95%, specificity 96%), useful when ultrasound equivocal and to exclude differentials and complications of acute cholecystitis.
Step 5: Management
IV antibiotics: ampicillin and gentamicin. (See CIAP)
Gentamicin 4-7 mg/kg daily + Ampicillin 2 g six hourly
- NBM, IV fluids
- Monitor fluid input / output
- Analgesia (opiates, NSAIDS)
Step 6: Seek and treat complications
- Cholecystoenteric fistula
- Gallstone ileus
- Emphysematous cholecystitis.
Further References and Resources
- Australasian College for Emergency Medicine (ACEM) - Policy on the Use of Bedside Ultrasound by Emergency Physicians
- NSW Adult Sepsis Toolkit
- BMJ Best Practice - Cholecystitis (Available via CIAP subscription)
- Up to date resources (requires login) Acute cholecystitis: Pathogenesis, clinical features, and diagnosis