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, it 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 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 / epigastric pain, around the waist, or to the back, scapula, or right shoulder, left upper back.
Fever may be present.
profound weight loss
various medication (oral contraceptive pill and clofibrate).
Uncommonly, acute cholecystitis may present even if the patient has had a cholecystectomy.
Step 2: Is the patient stable?
Initiate resuscitation if unstable. If the patient has severe sepsis, initiate the 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 possible pneumonia, 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. See Policy (P21) on the Use of bedside Ultrasound by Emergency Physicians.
- A useful resource produced by the American College of Emergency Physicians.
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. (Click here to view the eTG Therapeutic Guidelines)
NBM, IV fluids
Monitor fluid input / output
Analgesia (opiates, NSAIDS).
Step 6: Seek and treat complications