Acute Cholecystitis
Definition
Acute cholecystitis is the acute inflammation of the gallbladder, most commonly developing as a complication of gallstone disease (cholelithiasis) (1).
Epidemiology
Gallstone disease is a significant surgical issue in Malaysia. While comprehensive national prevalence data for acute cholecystitis remains limited, local hospital-based studies provide valuable insights. A study at Hospital Tuanku Ja'afar Seremban on patients undergoing laparoscopic cholecystectomy found that 39.5% of cases were for acute cholecystitis (2). The study population included a mix of ethnicities: 61% Malay, 17% Chinese, and 18.5% Indian (2). Another Malaysian study on the natural history of asymptomatic gallstones noted a cohort distribution of 50.7% Chinese, 39.4% Malay, and 9.9% Indian, and found that females are over three times more likely than males to develop symptoms from gallstones (3). The mean age for patients presenting with acute cholecystitis in the Seremban study was 48.25 years (2). Globally, acute cholecystitis is a common cause of abdominal pain, accounting for 3-10% of hospital admissions for this symptom (4).
[Specific prevalence and incidence data for acute cholecystitis across all of Malaysia was not found in the latest national health surveys; the provided data is from single-centre studies and should be interpreted with this limitation in mind].
Pathophysiology
The disease process is typically initiated by the obstruction of the cystic duct, the tube that drains bile from the gallbladder. In over 90-95% of cases, this obstruction is caused by an impacted gallstone (calculous cholecystitis) (1, 4). The blockage traps bile within the gallbladder, leading to increased intraluminal pressure and distension. This triggers an inflammatory cascade, initially chemical, due to the irritating effect of concentrated bile salts on the gallbladder mucosa. The inflamed and oedematous gallbladder wall can become ischaemic as intramural vessels are compressed, potentially leading to necrosis and gangrene. Secondary bacterial infection is common, with organisms typically ascending from the duodenum (1, 5).
Classification
The Tokyo Guidelines 2018 (TG18) provide a widely accepted severity grading system which is crucial for guiding management (6):
Grade I (Mild): Acute cholecystitis in a healthy patient with no organ dysfunction and only mild inflammatory changes in the gallbladder.
Grade II (Moderate): Associated with any one of the following: elevated white blood cell count (>18,000/mm³), a palpable tender mass in the right upper quadrant, duration of symptoms >72 hours, or marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).
Grade III (Severe): Associated with dysfunction of one or more organ systems (cardiovascular, neurological, respiratory, renal, hepatic, or haematological).
Clinical Presentation
The classic presentation involves a steady, severe pain in the right upper quadrant (RUQ) or epigastrium, often lasting longer than six hours.
Diagnostic Clues: A positive Murphy's sign (inspiratory arrest during deep palpation of the RUQ) is a classic physical finding with high specificity (5).
Common Symptoms (>50%):
Right upper quadrant or epigastric pain
Nausea and vomiting
Fever (usually low-grade) (1)
History of preceding fatty food ingestion (~1 hour before pain onset) (5)
Less Common Symptoms (10-50%):
Pain radiating to the right shoulder or back (1)
Anorexia
Jaundice (may suggest a common bile duct stone) (7)
⚠️ Red Flag Signs & Symptoms: High fever with chills, haemodynamic instability (hypotension, tachycardia), or signs of peritonism (involuntary guarding, rebound tenderness) suggest severe or complicated cholecystitis (e.g., gangrene, perforation) and require immediate senior review and resuscitation (6).
Complications
Gangrenous Cholecystitis: Ischaemia and necrosis of the gallbladder wall.
Perforation: A localised or free rupture of the gallbladder, leading to an abscess or generalised peritonitis.
Empyema: The gallbladder becomes filled with pus.
Cholecystoenteric Fistula: An abnormal connection forms between the gallbladder and an adjacent part of the gut, potentially leading to gallstone ileus.
Mirizzi Syndrome: A large stone impacted in the cystic duct or gallbladder neck externally compresses the common hepatic duct, causing jaundice.
Prognosis
With timely treatment, the prognosis for acute cholecystitis is generally good. Early laparoscopic cholecystectomy is associated with a low mortality rate (<1%) in low-risk patients (Grade I) (6). The prognosis worsens significantly with increasing severity. Grade III cholecystitis is associated with substantial morbidity and mortality due to underlying organ failure (6).
Differential Diagnosis
Biliary Colic: This is a key differential, also caused by gallstones. It is distinguished by its intermittent nature and shorter duration; the pain typically resolves within 6 hours as the obstructing stone falls back into the gallbladder. There are usually no systemic signs of inflammation like fever or leukocytosis (5).
Acute Pancreatitis: Consider this especially if the pain is epigastric and radiates to the back. An elevated serum amylase or lipase (typically >3 times the upper limit of normal) is the key distinguishing investigation, although mild elevations can occur in cholecystitis (8).
Peptic Ulcer Disease (PUD): Epigastric pain is a shared feature. The pain of PUD may be related to meals (either relieved or worsened) and can be associated with bloating or early satiety. A history of NSAID use or H. pylori infection is suggestive. Perforated PUD can present with peritonism, similar to a perforated gallbladder (1).
Acute Cholangitis: This involves inflammation and infection of the entire biliary tree, not just the gallbladder. It is classically distinguished by Charcot's triad (fever, RUQ pain, and jaundice). The presence of significant jaundice and markedly elevated liver enzymes should raise suspicion for cholangitis over isolated cholecystitis (8).
Investigations
Immediate & Bedside Tests
Vital Signs Monitoring: Essential to detect signs of sepsis or clinical deterioration (the action), which are hallmarks of severe (Grade III) disease requiring immediate resuscitation (the rationale) (6).
Diagnostic Workup
Full Blood Count: Crucial to identify leukocytosis (the rationale), which is a key diagnostic criterion and part of the severity assessment for acute cholecystitis (the action) (6).
Liver Function Tests (LFTs): Performed to assess for biliary obstruction (the action). While mild elevations of ALP and bilirubin can occur from gallbladder inflammation, significant elevations should raise suspicion of a common bile duct stone (choledocholithiasis) or Mirizzi syndrome (the rationale) (1).
C-Reactive Protein (CRP): An elevated CRP is a supportive marker of systemic inflammation (the rationale) and is included in the TG18 diagnostic criteria (the action) (6).
Renal Profile & Electrolytes: Necessary to assess for dehydration and acute kidney injury (the action), which can be a sign of sepsis-induced organ dysfunction (Grade III disease) (the rationale) (6).
First-Line Imaging: "Abdominal Ultrasound is the initial imaging test of choice. It is highly effective for detecting gallstones, gallbladder wall thickening (>3mm), pericholecystic fluid, and eliciting a sonographic Murphy's sign (the rationale), which together can confirm the diagnosis non-invasively at the bedside (the action) (4, 6)."
Gold Standard: While ultrasound is the primary diagnostic tool, the definitive diagnosis is clinical, supported by imaging and lab findings. In equivocal cases, Hepatobiliary Iminodiacetic Acid (HIDA) Scan can be used. Failure of the gallbladder to be visualised on a HIDA scan is highly specific for cystic duct obstruction (the rationale), confirming the diagnosis when ultrasound is inconclusive (the action) (1).
Computed Tomography (CT) Scan: A CT scan is not typically a first-line test for diagnosis but is valuable for assessing for complications (the action) such as perforation, abscess formation, or emphysematous cholecystitis, especially in severely ill patients (the rationale) (4).
Management
Management Principles
The management of acute cholecystitis focuses on initial medical stabilisation with intravenous fluids and antibiotics, followed by definitive surgical removal of the gallbladder (cholecystectomy) (6, 7).
Acute Stabilisation (The First Hour)
Airway/Breathing: "Administer supplemental oxygen if the patient is hypoxic to maintain SpO2 >94% (the action), crucial for preventing tissue hypoxia in the context of sepsis and systemic inflammation (the rationale)."
Circulation: "Secure two large-bore IV cannulas and administer a stat fluid bolus (e.g., IV Normal Saline or Hartmann's solution 10-20mL/kg) if the patient is hypotensive or tachycardic (the action), to restore intravascular volume and improve end-organ perfusion (the rationale)."
Disability/Exposure: "Administer adequate analgesia, such as an injectable NSAID (e.g., Ketorolac 30mg) or an opioid (e.g., Morphine 2.5-5mg IV), to control the severe pain (the action), which reduces patient distress and the systemic stress response (the rationale). Keep the patient nil by mouth (NBM) to rest the gallbladder."
Definitive Therapy
Antibiotic Therapy
According to the Malaysian National Antibiotic Guideline 2024, empirical antibiotic therapy should target common biliary pathogens (Enterobacteriaceae, Enterococcus).
First-Line Treatment (Grade I & II):
IV Ampicillin/Sulbactam 1.5-3g 6-hourly OR
IV Cefuroxime 1.5g 8-hourly + IV Metronidazole 500mg 8-hourly (if anaerobes are suspected).
For Penicillin Allergy: IV Ciprofloxacin 400mg 12-hourly + IV Metronidazole 500mg 8-hourly (9).
Escalation (Grade III / Healthcare-associated):
IV Piperacillin/Tazobactam 4.5g 6-hourly (9).
The justification for antibiotics is to treat or prevent secondary bacterial infection of the inflamed gallbladder (the action), which is crucial for controlling sepsis and preventing complications like empyema or perforation (the rationale).
Surgical Therapy (Cholecystectomy)
The definitive treatment is the surgical removal of the gallbladder. The timing depends on the severity and patient fitness.
Early Laparoscopic Cholecystectomy: This is the recommended approach for Grade I and II cholecystitis, ideally performed within 72 hours of symptom onset or during the same hospital admission (6, 10). Performing surgery early reduces overall length of hospital stay and the risk of recurrent gallstone-related problems before the planned operation (10).
Delayed Cholecystectomy: In severe (Grade III) disease, the patient is often too unstable for immediate surgery. The priority is resuscitation and source control via other means. Surgery is typically delayed for several weeks to allow the acute inflammation to resolve (6).
Gallbladder Drainage: For high-risk patients with Grade II or III cholecystitis who are unfit for surgery, an emergency drainage procedure is indicated. This can be done via percutaneous cholecystostomy (a drain inserted through the skin into the gallbladder under radiological guidance) or endoscopically (6).
Supportive & Symptomatic Care
Intravenous Fluids: To maintain hydration while the patient is nil by mouth.
Analgesia: Regular scheduling of painkillers is essential for patient comfort.
Antiemetics: To control nausea and vomiting (e.g., IV Metoclopramide 10mg).
Thromboprophylaxis: For all admitted patients who are not mobile, to prevent deep vein thrombosis.
Key Nursing & Monitoring Instructions
Strict hourly input/output charting to assess fluid status.
Monitor vital signs at least 4-hourly; escalate to hourly if the patient is unstable.
Maintain patient as Nil By Mouth (NBM).
Administer IV antibiotics and analgesia as per schedule.
Inform medical staff if systolic BP drops below 100 mmHg, heart rate >110 bpm, urine output is <0.5mL/kg/hr, or if there is any new confusion or increased abdominal pain.
Long-Term Plan & Patient Education
Follow-up: Post-cholecystectomy, patients are typically reviewed in the surgical clinic 2-4 weeks after discharge.
Dietary Advice: After surgery, most patients can return to a normal diet. There is no gallbladder to store bile, so bile trickles continuously into the gut. Some patients may experience loose stools, especially after fatty meals, which usually improves over time (7).
Education: Explain the reasons for the surgery, the expected recovery course, and warning signs of complications (e.g., fever, jaundice, worsening abdominal pain) that should prompt an immediate return to hospital.
When to Escalate
Call Your Senior (MO/Specialist) if:
The diagnosis is uncertain.
The patient shows signs of Grade II (Moderate) or Grade III (Severe) cholecystitis.
The patient fails to improve or deteriorates after 24-48 hours of conservative treatment.
There are signs of sepsis or shock (hypotension, persistent tachycardia, oliguria).
Imaging suggests a significant complication (e.g., perforation, abscess, emphysematous changes).
Referral Criteria
Refer to the Interventional Radiology team for consideration of percutaneous cholecystostomy in a patient who is unfit for surgery.
Refer to the Intensive Care Unit (ICU) team for any patient with Grade III cholecystitis demonstrating organ dysfunction.
References
MSD Manual Professional Edition. (n.d.). Acute Cholecystitis. Retrieved from https://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Tan, S. H., Burud, I. A. S., Lau, S. L., Hove, A., Roy, P., & Mahad, D. S. (2017). Factors influencing the outcome of laparoscopic cholecystectomy at Hospital Tuanku Ja’afar Seremban, Malaysia. Rawal Medical Journal, 42(4), 541-545. https://www.researchgate.net/publication/320618298_Factors_influencing_the_outcome_of_laparoscopic_cholecystectomy_at_Hospital_Tuanku_Ja'afar_Seremban_Malaysia_Tan_Shi_Hun_Ismail_Abdul_Sattar_Burud_Lau_Shi_Lin_Annete_Hove_Pooja_Roy_Dorcas_Selwyn
Goon, C. D., & Jayakumar, C. R. (2015). Natural history of asymptomatic gallstones: differential behaviour in male and female subjects. Medical Journal of Malaysia, 70(6), 336-340. https://www.e-mjm.org/2015/v70n6/asymptomatic-gallstones.pdf
Radiopaedia. (n.d.). Acute cholecystitis. Retrieved from https://radiopaedia.org/articles/acute-cholecystitis
StatPearls. (2024). Acute Cholecystitis. NCBI Bookshelf. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459171/
Yokoe, M., Hata, J., Takada, T., Strasberg, S. M., Asbun, H. J., Wakabayashi, G., ... & Tokyo Guidelines 2018 working group. (2018). Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 41-54. https://doi.org/10.1002/jhbp.515
University Malaya Medical Centre. (n.d.). Patient Information Leaflet on Cholecystitis. Retrieved from https://www.ummc.edu.my/files/HealthPhamplet/CHOLECYSTITIS%20EDITED%20%282%29.pdf
BMJ Best Practice. (2024). Acute Cholecystitis. Retrieved from https://bestpractice.bmj.com/topics/en-gb/78
Ministry of Health Malaysia. (2024). National Antimicrobial Guideline 2024 (4th Edition). Pharmaceutical Services Programme, Ministry of Health Malaysia. https://pharmacy.moh.gov.my/en/documents/national-antimicrobial-guideline-nag-2024-4th-edition.html
NICE. (2014). Gallstone disease: diagnosis and management (CG188). National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/cg188
