Acute cholecystitis

Disease Description (Causes and Symptoms)

• Definition: A condition in which partial or complete obstruction of the cystic duct causes mechanical, chemical, and bacterial inflammation within the gallbladder (acute cholecystitis).
• Main causes
  • Calculous (72–93%): Gallstones obstruct the cystic duct, increasing pressure within the gallbladder → ischemia and inflammation occur.
  • Acalculous (approximately 5–10%): Occurs due to severe infections (sepsis, typhoid fever), burns, trauma, long-term parenteral nutrition, vascular ischemia, and other causes; it progresses more rapidly than calculous cholecystitis and carries a higher risk of complications (necrosis and perforation).
• Pathophysiology summary: Cystic duct obstruction → bile stasis and mucosal injury → bacterial proliferation/inflammation → gallbladder wall edema and ischemia; in severe cases, necrosis and perforation.
• Main symptoms
  • Right upper quadrant pain (persistent, possibly radiating to the back or right scapula), fever, nausea, and vomiting
  • Sonographic Murphy sign, in which pain worsens when inhaling during palpation
  • Test findings: increased white blood cell count, elevated CRP, and, in some cases, mild elevations in liver enzymes and bilirubin

Treatment Methods

• Initial (emergency) management
  • Fasting (NPO), securing intravenous access and fluid replacement, and antiemetics
  • Analgesics (e.g., non-opioid or opioid analgesics, depending on clinical judgment) and antispasmodics
  • Empirical antibiotics: Agents covering enteric Gram-negative bacteria and anaerobes are recommended (e.g., piperacillin-tazobactam alone, or a third-generation cephalosporin + metronidazole). In severe or high-risk cases, broad-spectrum antibiotics (such as carbapenems) may be considered — the specific choice and dosage are determined by the attending physician.
• Image-guided and endoscopic procedures
  • In cases of severe complications (abscess, necrosis, or perforation) or in patients with high surgical risk or contraindications to surgery: percutaneous cholecystostomy or endoscopic drainage may be considered
  • If a coexisting common bile duct stone is suspected, biliary drainage and stone removal by ERCP (endoscopic retrograde cholangiopancreatography) may be necessary
• Surgical treatment
  • Standard treatment: laparoscopic cholecystectomy. Performing it during the acute phase (within 7 days of symptom onset, ideally within 72 hours) is recommended because it reduces complications and length of hospital stay (depending on the clinical condition and hospital resources).
  • If the patient is unstable or at high risk, conservative treatment or drainage is performed first for stabilization, followed by delayed cholecystectomy
• Lifestyle management and precautions
  • During the acute phase, avoid high-fat foods and drink sufficient fluids (unless otherwise instructed by a doctor)
  • Check for side effects and drug interactions when taking antibiotics or analgesics
  • Even if symptoms improve, there is a risk of recurrence (approximately 20% of patients treated with medical treatment alone experience recurrence within 1 year) — consult the attending physician regarding long-term management

Checklist Before an Outpatient Visit (Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of currently taken medications and supplements (including dosages if possible)
  • Past medical history (surgeries, allergies, and chronic diseases) and records of recent hospitalizations or emergency-room visits
  • Recent test results (blood tests and imaging results and findings, such as ultrasound, CT, or HIDA)
  • The onset and course of symptoms (date of pain onset, frequency, intensity, and triggers), whether fever or vomiting occurred, and changes in stool or urine color
• Items to tell the doctor first during the outpatient visit
  • Allergies (especially to antibiotics such as penicillins and cephalosporins)
  • Whether you are taking anticoagulants (important when planning surgery)
  • Possibility of pregnancy or whether you are breastfeeding

General Example Questions to Ask the Doctor

• What are the expected side effects of this medication (or antibiotic)? How long should I take it?
• Am I a candidate for surgery? What are the recommended timing and method of surgery (laparoscopic vs. open), and why?
• What warning symptoms mean that I should return to the emergency room (when should I contact the hospital or visit again)?
• What lifestyle changes should I make to reduce the possibility of recurrence and help prevent it?
• Why do I need additional tests (ultrasound, HIDA, CT, or ERCP), and what are their risks?

Examples of Disease-Specific Questions

• If I am elderly or have cardiovascular or pulmonary disease, which would be safer for me: nonsurgical treatment (percutaneous cholecystostomy) or surgery?
• If a common bile duct stone is suspected, is ERCP needed first, or should the test be performed after cholecystectomy?

(Summary for Reference)

• Gallstones account for most cases (72–93%), while acalculous acute cholecystitis is uncommon but progresses more rapidly and carries a higher risk of complications.
• Diagnosis is usually based on clinical findings (right upper quadrant pain, fever, and increased white blood cell count) and ultrasound (gallstones, gallbladder wall thickening >3 mm, pericholecystic fluid, and sonographic Murphy sign); HIDA (positive when the gallbladder is not visualized) and CT may be used as supportive tests when necessary.
• Treatment consists of fasting, fluids, analgesics, and antibiotics, followed, whenever possible, by early laparoscopic cholecystectomy as the standard treatment. In high-risk patients, stabilization with drainage followed by planned surgery may be considered.