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Internal Medicine›Condition·Updated Apr 17, 2026·v1

Cholecystitis

Acute cholecystitis is a common inflammatory condition of the gallbladder, usually secondary to gallstones. Diagnosis relies on the Tokyo Guidelines 2018, integrating clinical signs (Murphy's sign), laboratory markers (WBC, CRP), and imaging (Ultrasound). Early laparoscopic cholecystectomy is the preferred treatment. For patients with significant comorbidities or organ failure, gallbladder drainage (PTGBD or EUS-GBD) serves as a vital alternative.

High Evidence114 references·6,498 words·26 min read·v1
cholecystitisgallstonesbiliary_surgeryhepatologyemergency_medicine

Quick Reference

RxDrug of choiceCefazolin (1 g IV daily) for Grade I/II; Piperacillin-Tazobactam (3.375 g IV every 6h) for Grade III
AltAlternativesCiprofloxacin plus Metronidazole; Ampicillin-Sulbactam
⊘AvoidAvoid delaying surgery beyond 7 days in fit patients; avoid conservative management in pregnant patients due to high recurrence risk.
DxTest of choiceRight Upper Quadrant Ultrasound (Initial); HIDA Scan (Gold standard for ductal patency)
ScKey scoreTokyo Guidelines 2018 (TG18) Severity Grading
→When to referRefer to General Surgery immediately upon suspected diagnosis; refer to Interventional Radiology or Advanced Endoscopy if the patient is unfit for surgery.
Acute cholecystitis is best managed with early laparoscopic cholecystectomy within 72 hours; use TG18 criteria to grade severity and guide the timing of intervention.
Acute cholecystitis is a surgical emergency characterized by inflammation of the gallbladder wall, most commonly resulting from cystic duct obstruction by gallstones (calculous cholecystitis). While biliary colic is transient, acute cholecystitis involves persistent pain, systemic inflammation, and a risk of progression to gallbladder gangrene or perforation if not managed promptly. Modern management has shifted toward early laparoscopic cholecystectomy—ideally within 72 hours of symptom onset—as it reduces hospital stay and prevents recurrent biliary events. In critically ill or surgically unfit patients, acalculous cholecystitis (inflammation without stones) must be suspected, often requiring percutaneous or endoscopic drainage. The Tokyo Guidelines 2018 (TG18) provide the gold-standard framework for diagnosis and severity grading, which dictates the urgency of surgical intervention versus medical stabilization.

Overview and Recommendations

Background

  • •Distinguish between acute calculous cholecystitis (ACC), which accounts for 90-95% of cases and is triggered by gallstone impaction in the cystic duct, and acute acalculous cholecystitis (AAC), which occurs in critically ill patients due to bile stasis and ischemia.
  • •Recognize the inflammatory cascade where cystic duct obstruction leads to bile stasis, chemical irritation of the mucosa, and the release of inflammatory mediators like prostaglandins and Vascular Endothelial Growth Factor A (VEGF-A), which increases vascular permeability and wall edema.
  • •Identify high-risk populations, including patients with , the elderly, and those with , who are more prone to severe variants like emphysematous or gangrenous cholecystitis.
  • •Consider rare variants such as xanthogranulomatous cholecystitis, which can mimic gallbladder cancer, or , which presents as a fibroinflammatory mass and may respond to steroids.
  • •Understand the role of secondary infection (bactibilia), which occurs in 20-70% of cases, typically involving enteric organisms like E. coli, Klebsiella, and Enterococcus.

Evaluation

  • •Suspect acute cholecystitis when a patient presents with steady, severe right upper quadrant (RUQ) or epigastric pain lasting more than 6 hours, often radiating to the right shoulder or scapula (Boas' sign).
  • •Perform a focused physical exam to elicit Murphy's sign, defined as the abrupt arrest of inspiration during deep palpation of the RUQ; while highly specific, this may be absent in elderly patients or those with advanced neuropathy.
  • •Assess for systemic signs of inflammation, including fever, tachycardia, and localized guarding; generalized peritonitis should raise immediate concern for gallbladder perforation.
  • •Order a (CBC) and C-reactive protein (CRP); a white blood cell count > 13.0 x 10^9/L or a Neutrophil-to-Lymphocyte Ratio (NLR) > 5.48 are strong predictors of gangrenous changes.
  • •Obtain liver function tests (LFTs) to screen for concomitant or Mirizzi syndrome; significant jaundice (bilirubin > 4 mg/dL) suggests common bile duct involvement.
  • •Calculate the Triglyceride-Glucose (TyG) index—ln (fasting triglyceride × fasting glucose / 2)—as a higher index is associated with increased metabolic stress and disease severity.
  • •Order a RUQ Ultrasound as the first-line imaging study to look for gallbladder wall thickening (> 4 mm), pericholecystic fluid, and the presence of or sludge.
  • •Measure the peak systolic cystic artery velocity (CaV) during ultrasound; a CaV ≥ 40 cm/s is an independent sonographic predictor of acute cholecystitis in emergency settings.
  • •Obtain a contrast-enhanced CT scan if complications like gangrene, emphysematous gas, or perforation are suspected, or if the diagnosis remains unclear after ultrasound.
  • •Utilize Cholescintigraphy (HIDA scan) as the gold standard for assessing cystic duct patency; non-visualization of the gallbladder within 60-240 minutes is diagnostic of obstruction.
  • •Apply the Tokyo Guidelines 2018 (TG18) criteria for definitive diagnosis: requires one local sign (e.g., Murphy's sign), one systemic sign (e.g., fever/elevated CRP), and one confirmatory imaging finding.

Management

  • •Stabilize the patient immediately with NPO status (nothing by mouth), aggressive intravenous crystalloid resuscitation, and adequate .
  • •Administer empirical such as Cefazolin 1 g IV every 24 hours for Grade I or II cases; for severe cases or suspected sepsis, escalate to broader enteric coverage.
  • •Perform early (LC) within 72 hours of symptom onset for most patients, as this reduces the risk of conversion to open surgery and prevents interval biliary complications.
  • •Classify severity using TG18: Grade I (mild) allows for early LC; Grade II (moderate) requires early LC or drainage if inflammation is severe; Grade III (severe) requires organ support and often initial drainage.
  • •Utilize ultrasound-guided T7-11 intercostal nerve blocks or subcostal transversus abdominis plane (TAP) blocks with 40 mL of 0.3% ropivacaine to reduce postoperative opioid requirements.
  • •Employ the 'critical view of safety' during surgery to prevent bile duct injury; if anatomy is obscured by dense adhesions, pivot to a bailout strategy like subtotal cholecystectomy.
  • •Refer high-risk surgical candidates (ASA score > 3) for Percutaneous Transhepatic Gallbladder Drainage (PTGBD) or Endoscopic Ultrasound-guided Gallbladder Drainage (EUS-GBD) as a bridge to surgery or definitive therapy.
  • •Monitor for 'red flags' of gangrenous cholecystitis, such as age > 51, diabetes, or gallbladder width > 4 cm on imaging, which necessitate urgent surgical intervention.
  • •Manage perforated cholecystitis with same-admission surgery rather than interval surgery to decrease the high risk of conversion to open procedures (55% in delayed cases).
  • •Avoid delaying surgery beyond 7 days from symptom onset, as organized adhesions significantly increase the technical difficulty and complication rates.
  • •Continue postoperative antibiotics for 4 days only if there is evidence of ongoing infection or gallbladder rupture; uncomplicated Grade I cases often do not require post-surgical antibiotics.
  • •Schedule follow-up for patients who underwent subtotal cholecystectomy, as approximately 55% may develop symptomatic stones in the gallbladder remnant requiring completion cholecystectomy.
  • •Ensure pregnant patients are managed operatively, preferably in the second trimester, to avoid the high recurrence rates associated with conservative management.

Board Review — High Yield

  • •Murphy's Sign — Arrest of inspiration on deep RUQ palpation; the most specific physical exam finding for acute cholecystitis.
  • •Boas' Sign — Hyperesthesia or referred pain at the inferior angle of the right scapula.
  • •Emphysematous Cholecystitis — Gas in the gallbladder wall/lumen; strongly associated with [[diabetes mellitus]] and Clostridium species; requires urgent surgery.
  • •Acalculous Cholecystitis — Occurs in critically ill patients (sepsis, burns, TPN) due to ischemia and bile stasis; high risk of gangrene (45%).
  • •HIDA Scan — Positive test is the failure to visualize the gallbladder, indicating cystic duct obstruction.
  • •Mirizzi Syndrome — Extrinsic compression of the common hepatic duct by a stone impacted in the gallbladder neck/cystic duct, causing jaundice.
  • •Quincke's Triad — RUQ pain, jaundice, and hemobilia; suggests a rare complication like cystic artery pseudoaneurysm.
  • •Tokyo Guidelines (TG18) — Standardized criteria requiring local inflammation, systemic inflammation, and imaging confirmation for diagnosis.

Deep Dive — Evidence Details

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