Acute cholecystitis is an inflammatory condition of the gallbladder, most commonly precipitated by the obstruction of the cystic duct. If not managed promptly, it can progress from localized inflammation to systemic sepsis or organ perforation.

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1. Clinical Presentation and Symptoms

The symptoms of acute cholecystitis are distinct from chronic biliary colic due to the presence of active inflammation and infection.

• Persistent RUQ Pain: Steady, severe pain in the right upper quadrant lasting longer than 6 hours.

• The Murphy Sign: A classic physical exam finding where the patient abruptly stops inspiration (breathing in) upon deep palpation of the right upper quadrant.

• Systemic Inflammatory Response: Presence of fever (usually $>38^\circ\text{C}$), tachycardia, and chills.

• Nausea and Vomiting: Occurs in approximately 60–90% of patients.​

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Pathophysiology and Causes

• Gallstone Obstruction (95%): Hardened deposits of cholesterol or bilirubin block the cystic duct, leading to bile stasis and mucosal ischemia.

• Acalculous Cholecystitis (5%): Occurs without stones, often in the setting of critical illness, severe trauma, or prolonged parenteral nutrition (IV feeding).

• Infectious Agents: Secondary bacterial infection (commonly E. coli, Klebsiella, or Enterococcus) occurs in about 50–70% of cases.

 

Risk Factors: Who is Affected?

Demographic data from the National Institutes of Health (NIH) indicates that specific populations are at higher risk:

• Age and Gender: Women are significantly more likely to develop the condition, particularly those over age 40.

• Metabolic Factors: Obesity and rapid weight loss are primary drivers.

• Diabetes Mellitus: Diabetics are at higher risk for "emphysematous cholecystitis," a severe form involving gas-forming bacteria.

• Pregnancy: Hormonal shifts during pregnancy slow gallbladder emptying, promoting stone formation.

 

Diagnosis and Treatment

Diagnosis is typically reached through a combination of imaging and laboratory findings based on the Tokyo Guidelines (TG18).

• Imaging: Ultrasound is the primary tool, looking for a "sonographic Murphy sign" and gallbladder wall thickening ($>4\text{mm}$).

• Surgical Intervention: Early Laparoscopic Cholecystectomy (removal of the gallbladder) is the gold standard of care, preferably within 24–72 hours of admission.

• Medical Management: Intravenous fluids, pain control (NSAIDs or opioids), and broad-spectrum antibiotics.

 

Complications

Failure to treat the inflammation can result in:

• Gangrenous Cholecystitis: Tissue death due to pressure and lack of blood flow.

• Gallbladder Perforation: A rupture leading to a localized abscess or generalized peritonitis.

• Cholecystoenteric Fistula: An abnormal connection forming between the gallbladder and the bowel.

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Prevention Strategies

• Dietary Consistency: Maintaining a diet high in fiber and low in saturated fats.

• Weight Stability: Avoiding "yo-yo" dieting or extreme caloric restriction, which alters bile chemistry.

• Physical Activity: Regular exercise has been shown to reduce the risk of gallstone formation by improving metabolic health.

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