Acute calculous cholecystitis - Revision history

Danbot: Strip excess bold

2026-03-22T09:29:25Z

Strip excess bold

← Older revision		Revision as of 09:29, 22 March 2026
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	==Background==		==Background==
	*Inflammation of the gallbladder caused by ~~'''~~obstruction of the cystic duct by gallstones~~'''~~		*Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones
	*Most common complication of [[cholelithiasis]]		*Most common complication of [[cholelithiasis]]
	*~~'''~~10-20% of patients with gallstones~~'''~~ will develop cholecystitis		*10-20% of patients with gallstones will develop cholecystitis
	*Risk factors (~~'''~~5 F's~~'''~~ — mnemonic):		*Risk factors (5 F's — mnemonic):
	**~~'''F'''emale~~, ~~'''F'''orty~~, ~~'''F'''ertile~~ (multiparity), ~~'''F'''at~~ (obesity), ~~'''F'''air~~ (Northern European descent)		**Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent)
	**Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)		**Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)
	*Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)		*Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)
	*Complications: ~~'''~~gangrenous cholecystitis~~'''~~ (20%), ~~'''~~perforation~~'''~~ (2-15%), ~~'''~~gallstone ileus~~'''~~, cholecystoenteric fistula, [[emphysematous cholecystitis]]		*Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, [[emphysematous cholecystitis]]

	==Clinical Features==		==Clinical Features==
	*~~'''~~RUQ pain~~'''~~ (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)		*RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)
	*Pain radiates to ~~'''~~right scapula or shoulder~~'''~~ (phrenic nerve irritation)		*Pain radiates to right scapula or shoulder (phrenic nerve irritation)
	*~~'''~~Nausea and vomiting~~'''~~ (common)		*Nausea and vomiting (common)
	*~~'''~~Fever~~'''~~ (low-grade; high fever suggests complications)		*Fever (low-grade; high fever suggests complications)
	*~~'''~~Murphy sign~~'''~~: inspiratory arrest during RUQ palpation (~~'''~~sensitivity ~65%~~'''~~)		*Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%)
	**~~'''~~Sonographic Murphy sign~~'''~~ (pain with probe pressure over sonographically visualized gallbladder) is more specific		**Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific
	*RUQ guarding, rebound tenderness (suggests peritonitis)		*RUQ guarding, rebound tenderness (suggests peritonitis)
	*~~'''~~Jaundice~~'''~~ suggests ~~'''~~[[choledocholithiasis]]~~'''~~ (common bile duct stone) or ~~'''~~[[cholangitis]]~~'''~~ (Charcot triad/Reynolds pentad)		*Jaundice suggests [[choledocholithiasis]] (common bile duct stone) or [[cholangitis]] (Charcot triad/Reynolds pentad)

	==Differential Diagnosis==		==Differential Diagnosis==
	*~~'''~~[[Biliary colic]]~~'''~~ (most important to distinguish — resolves within 4-6h)		*[[Biliary colic]] (most important to distinguish — resolves within 4-6h)
	*[[Choledocholithiasis]] / [[cholangitis]]		*[[Choledocholithiasis]] / [[cholangitis]]
	*[[Hepatitis]]		*[[Hepatitis]]
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	==Evaluation==		==Evaluation==
	===Labs===		===Labs===
	*~~'''~~WBC~~'''~~: leukocytosis (12,000-15,000); ~~'''~~WBC >20,000 suggests gangrenous or emphysematous cholecystitis~~'''~~		*WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis
	*~~'''~~LFTs~~'''~~: mild elevation of AST/ALT; ~~'''~~alkaline phosphatase and bilirubin elevated if CBD stone~~'''~~		*LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone
	*~~'''~~Lipase~~'''~~: rule out concurrent [[pancreatitis]] ([[gallstone pancreatitis]])		*Lipase: rule out concurrent [[pancreatitis]] ([[gallstone pancreatitis]])
	*~~'''~~Lactate~~'''~~: if septic		*Lactate: if septic
	*~~'''~~Blood cultures~~'''~~: if febrile or septic		*Blood cultures: if febrile or septic
	*~~'''~~Pregnancy test~~'''~~ in reproductive-age women		*Pregnancy test in reproductive-age women

	===RUQ Ultrasound (Test of Choice)===		===RUQ Ultrasound (Test of Choice)===
	*~~'''~~Sensitivity 88%, specificity 80%~~'''~~ for acute cholecystitis		*Sensitivity 88%, specificity 80% for acute cholecystitis
	*Findings:		*Findings:
	**~~'''~~Gallstones~~'''~~ (echogenic foci with posterior acoustic shadowing)		**Gallstones (echogenic foci with posterior acoustic shadowing)
	**~~'''~~Gallbladder wall thickening >3-4 mm~~'''~~ (nonspecific — also seen in CHF, ascites, hepatitis)		**Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis)
	**~~'''~~Pericholecystic fluid~~'''~~		**Pericholecystic fluid
	**~~'''~~Sonographic Murphy sign~~'''~~ (~~'''~~most predictive single finding~~'''~~)		**Sonographic Murphy sign (most predictive single finding)
	**Gallbladder distension (>10 cm long or >5 cm transverse)		**Gallbladder distension (>10 cm long or >5 cm transverse)
	*Combined findings increase diagnostic accuracy		*Combined findings increase diagnostic accuracy

	===HIDA Scan===		===HIDA Scan===
	*~~'''~~Most accurate test~~'''~~ for cholecystitis (sensitivity 97%, specificity 90%)		*Most accurate test for cholecystitis (sensitivity 97%, specificity 90%)
	*Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)		*Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)
	*Takes ~~'''~~1-4 hours~~'''~~ to complete — ~~'''~~not practical for acutely ill ED patients~~'''~~		*Takes 1-4 hours to complete — not practical for acutely ill ED patients
	*Use when US equivocal and diagnosis uncertain		*Use when US equivocal and diagnosis uncertain

	===CT===		===CT===
	*Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding		*Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
	*Useful for identifying ~~'''~~complications~~'''~~ (perforation, abscess, emphysematous changes)		*Useful for identifying complications (perforation, abscess, emphysematous changes)

	==Management==		==Management==
	===ED Management===		===ED Management===
	*~~'''~~NPO~~'''~~		*NPO
	*~~'''~~IV fluid resuscitation~~'''~~		*IV fluid resuscitation
	*~~'''~~Pain control~~'''~~:		*Pain control:
	**~~'''~~Ketorolac 15-30 mg IV~~'''~~ (shown to be effective and may reduce gallbladder inflammation)		**Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation)
	**'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated		**'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated
	*~~'''~~Antiemetics~~'''~~: ondansetron 4 mg IV		*Antiemetics: ondansetron 4 mg IV
	*~~'''~~Antibiotics~~'''~~ if complicated (febrile, septic, diabetic, immunocompromised):		*Antibiotics if complicated (febrile, septic, diabetic, immunocompromised):
	**~~'''~~Piperacillin-tazobactam 3.375-4.5g IV~~'''~~ OR		**Piperacillin-tazobactam 3.375-4.5g IV OR
	**~~'''~~Ceftriaxone 2g IV + metronidazole 500 mg IV~~'''~~		**Ceftriaxone 2g IV + metronidazole 500 mg IV
	**Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes		**Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes
	*~~'''~~Surgical consultation~~'''~~ for cholecystectomy		*Surgical consultation for cholecystectomy

	===Definitive Treatment===		===Definitive Treatment===
	*~~'''~~Laparoscopic cholecystectomy~~'''~~ (standard of care)		*Laparoscopic cholecystectomy (standard of care)
	*~~'''~~Early cholecystectomy (<72 hours)~~'''~~ preferred — associated with shorter hospital stays and lower complication rates<ref>Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). ''Ann Surg''. 2013;258(3):385-393. PMID 24022431</ref>		*Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates<ref>Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). ''Ann Surg''. 2013;258(3):385-393. PMID 24022431</ref>
	*~~'''~~Percutaneous cholecystostomy~~'''~~ for patients too unstable for surgery (critically ill, multiple comorbidities)		*Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities)

	===Special Populations===		===Special Populations===
	*~~'''~~Acalculous cholecystitis~~'''~~: occurs in critically ill/ICU patients without gallstones (5-10% of cases)		*Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases)
	*~~'''~~Emphysematous cholecystitis~~'''~~: gas-forming organisms; higher perforation risk; more common in diabetic men		*Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men
	*~~'''~~Elderly/diabetics~~'''~~: higher risk of complications, may present atypically		*Elderly/diabetics: higher risk of complications, may present atypically

	==Disposition==		==Disposition==
	*~~'''~~Admit all patients with acute cholecystitis~~'''~~		*Admit all patients with acute cholecystitis
	*~~'''~~ICU~~'''~~ if septic, gangrenous, or emphysematous cholecystitis		*ICU if septic, gangrenous, or emphysematous cholecystitis
	*~~'''~~Surgical consultation~~'''~~ in ED for early cholecystectomy		*Surgical consultation in ED for early cholecystectomy

	==See Also==		==See Also==

Danbot: Major update: HIDA accuracy, sonographic Murphy sign importance, early cholecystectomy evidence (ACDC trial), antibiotic regimens, morphine safety, Tokyo Guidelines, references with PMIDs

2026-03-21T19:48:41Z

Major update: HIDA accuracy, sonographic Murphy sign importance, early cholecystectomy evidence (ACDC trial), antibiotic regimens, morphine safety, Tokyo Guidelines, references with PMIDs

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Ostermayer at 22:24, 17 January 2026

2026-01-17T22:24:24Z

← Older revision		Revision as of 22:24, 17 January 2026
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	[[File:Gallstones 2.jpg \|thumb\|Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.]]		[[File:Gallstones 2.jpg \|thumb\|Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.]]
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	{{Gallbladder disease types}}		{{Gallbladder disease types}}
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	{{Gallbladder background}}		{{Gallbladder background}}
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	==Differential Diagnosis== <!--T:8-->		==Differential Diagnosis== <!--T:8-->

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	{{DDX RUQ}}		{{DDX RUQ}}
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Ostermayer: Marked this version for translation

2026-01-06T16:58:03Z

Marked this version for translation

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Ostermayer: Prepared the page for translation

2026-01-04T21:35:02Z

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Elcatracho: /* Local Signs */

2020-12-24T19:23:18Z

Local Signs

← Older revision		Revision as of 19:23, 24 December 2020
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	*Murphy Sign		*Murphy Sign
	**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>		**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
			*Boas sign: hyperaesthesia below the right scapula from referred pain<ref>Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x</ref>

	===Systemic signs===		===Systemic signs===

Rossdonaldson1: /* Complications */

2020-05-02T12:39:21Z

Complications

← Older revision		Revision as of 12:39, 2 May 2020
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	==Complications==		==Complications==
	===[[Gangrene]]===		===[[Gangrene]]===
	**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)		*Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
	**Consider if patient presents with sepsis in addition to cholecystitis		*Consider if patient presents with sepsis in addition to cholecystitis

	===Perforation===		===Perforation===
	**Occurs in 2% after development of gangrene		*Occurs in 2% after development of gangrene
	**Usually localized, leading to pericholecystic abscess		*Usually localized, leading to pericholecystic abscess
	*Gallstone [[Ileus]]
	**Due to cholecystoenteric fistula		===Gallstone [[Ileus]]===
	**[[Bowel obstruction]] due to impaction of gallstone at terminal ileum		*Due to cholecystoenteric fistula
	***Gallstone enters small bowel through biliary-duodenal fistula		*[[Bowel obstruction]] due to impaction of gallstone at terminal ileum
	**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone		**Gallstone enters small bowel through biliary-duodenal fistula
			*Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

	===Emphysematous cholecystitis===		===Emphysematous cholecystitis===
	**Due to secondary infection of GB by gas-forming organisms (C. perfringens)		*Due to secondary infection of GB by gas-forming organisms (C. perfringens)
	**Presents like cholecystitis but often progresses to sepsis and gangrene		*Presents like cholecystitis but often progresses to sepsis and gangrene
	**IV antibiotic and cholecystectomy are essential		*IV antibiotic and cholecystectomy are essential
	**Ultrasound report may mistake GB wall gas for bowel gas		*Ultrasound report may mistake GB wall gas for bowel gas
	**Mortality as high as 15% due to gangrene or perforation		*Mortality as high as 15% due to gangrene or perforation

	===Mirizzi Syndrome===		===Mirizzi Syndrome===
	**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation		*Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
	**Symptoms of acute cholecystitis + dilated intrahepatic ducts + [[jaundice]]		*Symptoms of acute cholecystitis + dilated intrahepatic ducts + [[jaundice]]
	**Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct		*Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
	***US and CT can usually delineate the fistula		**US and CT can usually delineate the fistula
	**Treatment = open cholecystectomy		*Treatment = open cholecystectomy

	==See Also==		==See Also==

Rossdonaldson1: /* Complications */

2020-05-02T12:38:40Z

Complications

← Older revision		Revision as of 12:38, 2 May 2020
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	==Complications==		==Complications==
	*[[Gangrene]]		===[[Gangrene]]===
	**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)		**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
	**Consider if patient presents with sepsis in addition to cholecystitis		**Consider if patient presents with sepsis in addition to cholecystitis
	*Perforation
			===Perforation===
	**Occurs in 2% after development of gangrene		**Occurs in 2% after development of gangrene
	**Usually localized, leading to pericholecystic abscess		**Usually localized, leading to pericholecystic abscess
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	***Gallstone enters small bowel through biliary-duodenal fistula		***Gallstone enters small bowel through biliary-duodenal fistula
	**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone		**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
	*Emphysematous cholecystitis
			===Emphysematous cholecystitis===
	**Due to secondary infection of GB by gas-forming organisms (C. perfringens)		**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
	**Presents like cholecystitis but often progresses to sepsis and gangrene		**Presents like cholecystitis but often progresses to sepsis and gangrene
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	**Ultrasound report may mistake GB wall gas for bowel gas		**Ultrasound report may mistake GB wall gas for bowel gas
	**Mortality as high as 15% due to gangrene or perforation		**Mortality as high as 15% due to gangrene or perforation
	*Mirizzi Syndrome
			===Mirizzi Syndrome===
	**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation		**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
	**Symptoms of acute cholecystitis + dilated intrahepatic ducts + [[jaundice]]		**Symptoms of acute cholecystitis + dilated intrahepatic ducts + [[jaundice]]

Rossdonaldson1: /* Evaluation */

2020-05-02T12:37:12Z

Evaluation

← Older revision		Revision as of 12:37, 2 May 2020
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	[[File:Ultrasonography of sludge and gallstones, annotated.jpg\|thumb\|Abdominal ultrasound showing biliary sludge and gallstones]]		[[File:Ultrasonography of sludge and gallstones, annotated.jpg\|thumb\|Abdominal ultrasound showing biliary sludge and gallstones]]
	[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
			[[File:Gallstones.png\|thumb\|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]
	[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
	~~[[File:Gallstones.png\|thumb\|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]~~

	===Workup===		===Workup===

Rossdonaldson1: /* Evaluation */

2020-05-02T12:36:43Z

Evaluation

← Older revision		Revision as of 12:36, 2 May 2020
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	[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
	[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
			[[File:Gallstones.png\|thumb\|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]

	===Workup===		===Workup===
	====Laboratory Findings====		====Laboratory Findings====

← Older revision		Revision as of 12:37, 2 May 2020
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	[[File:Ultrasonography of sludge and gallstones, annotated.jpg\|thumb\|Abdominal ultrasound showing biliary sludge and gallstones]]		[[File:Ultrasonography of sludge and gallstones, annotated.jpg\|thumb\|Abdominal ultrasound showing biliary sludge and gallstones]]
	[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:Cholecystitis_Neck_Stone_Bowra.gif\|thumbnail\|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
			[[File:Gallstones.png\|thumb\|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]
	[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]		[[File:GB_Thickening_Fluid_Bowra.gif\|thumbnail\|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
	~~[[File:Gallstones.png\|thumb\|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]~~

	===Workup===		===Workup===