Ep 174 – Acute cholecystitis

Acute cholecystitis is often seen in primary care patients and is a major complication of cholelithiasis. Symptomatic gallstones occur in up to 10% of patients before developing cholecystitis. Patients typically present with pain and localised tenderness, with or without guarding, in the upper right quadrant. In this episode, Dr Roger Henderson provides an overview of this common problem, looking at its risk factors, causes, symptoms, investigations and the treatment options available, as well as the prognosis and advice to give our patients to help prevent recurrence.

Key take-home points

• Acute cholecystitis develops in up to 10% of patients with symptomatic gallstones, with gallstones obstructing the cystic duct, leading to bile stasis, gallbladder distension and subsequent inflammation.
• In over 90% of cases, it is caused by complete cystic duct obstruction, usually due to an impacted gallstone in the gallbladder neck or cystic duct.
• The lifetime risk of developing gallstones is approximately 10–15% in developed countries.
• Risk factors include obesity, rapid weight loss, pregnancy and familial predisposition.
• It typically presents with right upper quadrant abdominal pain, with or without guarding, that may radiate to the right shoulder or back, and it is accompanied by fever, nausea and vomiting.
• Physical examination may reveal a positive Murphy’s sign, where the examiner's hand rests along the costal margin and deep inspiration causes pain.
• Laboratory investigations often reveal a leucocytosis and an inflammatory response, shown by an elevated C-reactive protein and erythrocyte sedimentation rate.
• Ultrasonography remains the first-line imaging modality due to its high sensitivity and specificity, accessibility and lack of radiation exposure.
• The management of acute cholecystitis includes supportive care, administration of intravenous fluids, analgesia and antibiotics targeting enteric pathogens.
• Early cholecystectomy, preferably laparoscopic, is the definitive treatment for most patients and is generally recommended within 72 hours of symptom onset to reduce the risk of complications and shorten hospital stay.
• For patients who are poor surgical candidates due to comorbid conditions, then a percutaneous cholecystostomy, where the gallbladder is drained using image-guided catheter placement, may be considered as a temporary measure.
• Complications of untreated or delayed treatment of acute cholecystitis include gallbladder gangrene and peritonitis.
• The long-term prognosis for patients with acute cholecystitis is good if timely and appropriate treatment is given.
• If the gallbladder perforates, the mortality rate is a significant 30%. Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality.

Key references

1. NICE. 2014. https://www.nice.org.uk/guidance/cg188.
2. Tokyo Guidelines. 2018. https://www.jshbps.jp/modules/en/index.php?content_id=47.
3. Indar AA, Beckingham IJ. BMJ. 2002;325(7365):639-643. doi: 10.1136/bmj.325.7365.639.
4. Dasari BVM, et al. Cochrane Database Syst Rev. 2013;2013(12):CD003327. doi: 10.1002/14651858.CD003327.pub4.
5. NICE. 2014. https://www.nice.org.uk/guidance/ipg508/chapter/1-recommendations.