Acute cholecystitis is inflammation of the gallbladder, usually because a gallstone blocks the cystic duct. It causes constant right upper abdominal pain and can lead to gangrene, perforation or sepsis.
Key symptoms
- Constant right upper abdominal pain lasting more than 6 hours
- Pain spreading to the right shoulder or back
- Fever
- Nausea and vomiting
- Often starts after a fatty meal
What you find on exam
- Right upper quadrant tenderness
- Murphy sign: the patient stops breathing in when the examiner presses under the right ribs
- Fever and fast heart rate
- Mild jaundice is possible; marked jaundice suggests a duct stone
- Guarding or rigidity if perforated
Tests
- Right upper quadrant ultrasound: stones, thick wall, fluid, sonographic Murphy sign
- Blood count: high white cell count
- Liver tests and lipase
- HIDA scan if ultrasound is unclear
- Blood cultures if septic
Treatment basics
- Nothing by mouth, IV fluids and pain control
- IV antibiotics such as ceftriaxone with metronidazole, or piperacillin-tazobactam if severe
- Early laparoscopic cholecystectomy, ideally within 72 hours
- Percutaneous cholecystostomy for patients too sick for surgery
- ERCP if a common bile duct stone is present
Red flags
- Fever, jaundice and right upper pain (cholangitis)
- Low blood pressure or confusion (sepsis)
- Peritonitis or gas in the gallbladder wall
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.