What is acute cholecystitis?
Acute cholecystitis is inflammation (swelling) of the gallbladder. It is usually caused by a gallstone that becomes trapped in one of the ducts or openings of the gallbladder.
The most common symptoms of acute cholecystitis are:
- a severe, sharp and constant pain in the upper right abdomen (tummy), which may be worse when breathing deeply or if the abdomen is touched
- a high temperature, or fever, of 38ºC (100.4ºF) or above
Acute cholecystitis is not usually a medical emergency. However, without treatment, it can lead to a number of serious and potentially fatal complications, such as:
- the death of the tissue of the gallbladder, called gangrenous cholecystitis, which can cause a serious infection
- the gallbladder splitting open, known as a perforated gallbladder
Read more about complications of acute cholecystitis.
Therefore, if acute cholecystitis is suspected, immediate referral to hospital is recommended.
What causes acute cholecystitis?
Gallstones are small stones that form in the gallbladder usually made of cholesterol.
If a gallstone becomes trapped in the main opening of the gallbladder, called the cystic duct, it can cause the gallbladder to become severely inflamed. Exactly why the blocked duct causes such severe inflammation is unclear.
Read more about the causes of acute cholecystitis.
Treating acute cholecystitis
Emergency surgery is usually required to treat complications that arise from acute cholecystitis.
Read more about how acute cholecystitis is treated.
Who is affected?
Acute cholecystitis is an uncommon complication of gallstones.
About 1-4% of people with gallstones experience infrequent episodes of pain, known as biliary colic. Around one in five of these people develop acute cholecystitis if their gallbladder is not surgically removed.
Acute cholecystitis symptoms
The symptoms of acute cholecystitis usually begin with a sudden sharp pain in the upper abdomen (tummy) that spreads towards the shoulder blade.
You may experience similar pain during an episode of biliary colic. However, pain associated with acute cholecystitis is usually persistent, whereas the pain of biliary colic usually goes away within one to five hours.
Read about the symptoms of gallstones for more information about biliary colic.
The affected section of the abdomen is usually extremely tender and breathing deeply can make the pain worse.
In about one in four cases of acute cholecystitis, the gallbladder swells to such an extent that you will be able to feel a bulge. This happens about 24 hours after the pain started.
Other symptoms of acute cholecystitis include:
- a high temperature (fever), which is usually mild and no higher than 38ºC (100.4ºF)
- nausea (feeling sick)
- vomiting (being sick)
- loss of appetite
- yellowing of the skin and the whites of the eyes (jaundice)
When to seek medical advice
It is important to determine whether your symptoms are the result of biliary colic, which does not require immediate treatment, or acute cholecystitis, which does require urgent treatment. Acute cholecystitis can often be determined as the cause of your symptoms if:
- you have a high temperature
- your symptoms of pain have persisted for more than eight hours
If you have either of the above two symptoms, contact your doctor immediately for advice. If this is not possible, phone your local out-of-hours service or call NHS Direct on 0845 4647.
If acute cholecystitis is not treated, there is an increased risk that complications will develop. It is important to get an expert opinion as soon as possible.
Acute cholecystitis causes
The causes of acute cholecystitis can be grouped into two main categories, calculous cholecystitis and acalculous cholecystitis.
Each of these types is discussed in more detail below.
Calculous cholecystitis is the most common, and usually less serious, type of acute cholecystitis. It accounts for around 90% of all cases.
Calculous cholecystitis develops when the main opening to the gallbladder, called the cystic duct, gets blocked by a gallstone or by a substance known as biliary sludge. Biliary sludge is a mixture of bile and small crystals of cholesterol and salt.
The blockage in the cystic duct results in a build-up of bile inside the gallbladder, which causes pressure inside the gallbladder to increase. For reasons still unclear, the rise in pressure inside the gallbladder causes the gallbladder to become inflamed and swollen.
In around one in five cases, the inflamed gallbladder becomes infected by bacteria. This can trigger the more serious complications of acute cholecystitis, such as gangrenous cholecystitis (tissue death inside the gallbladder).
Acalculous cholecystitis is usually a more serious type of acute cholecystitis. It often requires admission to an intensive care unit (ICU) for treatment.
Acalculous cholecystitis usually develops as a complication of a serious illness, infection or injury that damages the gallbladder. Possible causes for acalculous cholecystitis include:
- accidental damage to the gallbladder during major surgery
- serious injury or burns
- blood poisoning (sepsis)
- severe malnutrition
- HIV or AIDS
Things that increase the risk of getting acute cholecystitis include:
- being very overweight (obese), with a body mass index of 30 or more
- being female, as women are three times more likely to get acute cholecystitis than men, although symptoms tend to be more severe in men
- being middle-aged, as rates of acute cholecystitis are highest in people who are 40 to 60 years of age
- being of East Asian origin, as rates of acute cholecystitis are higher in people of Japanese and Chinese origin
Diagnosing acute cholecystitis
To diagnose acute cholecystitis, your doctor will physically examine your abdomen (tummy). If acute cholecystitis is suspected, you will be admitted to hospital for further tests.
Your doctor will probably carry out a simple test called Murphy’s sign. They will ask you to breathe in deeply while they firmly place their hand around your rib cage. Breathing in causes your gallbladder to move downwards. If you have cholecystitis, you will wince from sudden pain as your gallbladder contacts your doctor’s hand.
Your doctor will also refer you for a blood test to see whether you have a higher than normal amount of white blood cells in your blood. An increased white blood cell count is usually a sign of inflammation in your body.
If both of the above tests are positive, it is likely you will be referred to hospital for an ultrasound scan. This is where high-frequency sound waves are used to create an image of the inside of your body.
Other testing is usually only required if the results of the ultrasound are inconclusive or if it is thought complications may have occurred, such as the gallbladder becoming torn.
Other tests that may be carried out include:
- abdominal X-ray or computerised tomography (CT) scan, which uses X-rays and a computer to create detailed images of the inside of your body
- magnetic resonance imaging (MRI) scan, which uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body
- magnetic resonance imaging scan with cholangiopancreatography (MRCP), which may be carried out if it is thought that a gallstone may have moved from your gallbladder into a bile duct and is causing an obstruction
Acute cholecystitis treatment
If your doctor suspects you have acute cholecystitis, you will probably be admitted to hospital for treatment.
You will first be given an injection of antibiotics into a vein. Broad-spectrum antibiotics are used, which can kill a wide range of different bacteria.
Once your symptoms have stabilised, you may be sent home and given an appointment to return for surgical treatment (see below).
Alternatively, if your symptoms are particularly severe or you have a high risk of complications, you may be referred for surgery a few days after antibiotic treatment.
A cholecystectomy is the most widely used type of surgery for cases of acute cholecystitis.
A cholecystectomy is the surgical removal of the gallbladder. There are two types of cholecystectomy:
- laparoscopic cholecystectomy
- open cholecystectomy
These are described below.
Laparoscopic cholecystectomy is a type of ‘keyhole’ surgery. It is the most widely used type of cholecystectomy. A laparoscopic cholecystectomy is carried out under a general anaesthetic, which means you will be asleep during the operation and will not feel any pain.
During a laparoscopic cholecystectomy, the surgeon makes four small cuts, each about 1cm or smaller, in your abdomen (tummy) wall. One incision is made near your belly button and the other three made across your upper abdomen.
Your abdomen is inflated with carbon dioxide gas passed through the cuts. Inflating your abdomen gives the surgeon a better view of your organs and more room in which to work.
The surgeon passes an instrument called a laparoscope through one of the incisions. A laparoscope is a small, rigid tube that has a light source and a camera at one end. The camera transmits images of the inside of your abdomen to a television monitor.
The surgeon then passes small instruments down the other incisions to remove your gallbladder and any gallstones. After your gallbladder has been removed, the incisions are closed.
As this technique only involves making small cuts in your abdomen, you will not experience much pain afterwards. You should also recover quickly from the effects of the operation. Most people are able to return home either on the day of the surgery or the day after.
Read about laparoscopic cholecystectomy for more information about the procedure.
A laparoscopic cholecystectomy is not recommended if you:
- are in the third trimester (the last three months) of pregnancy
- for some people with cirrhosis (scarring of the liver)
In these circumstances, an open cholecystectomy may be recommended.
An open cholecystectomy may also be carried out if a planned laparoscopic cholecystectomy is not successful.
As with a laparoscopic cholecystectomy, an open cholecystectomy will be carried out under general anaesthetic so you will not feel any pain during the procedure. The surgeon will make a large cut in your abdomen to remove your gallbladder.
An open cholecystectomy is an effective method of treating acute cholecystitis, but has a longer recovery time than laparoscopic cholecystectomy. Most people take about six weeks to recover from an open cholecystectomy.
If your symptoms are severe or you are in poor health, your care team may decide immediate surgery is too dangerous.
In such circumstances, a temporary measure known as a percutaneous cholecystostomy may be carried out. A percutaneous cholecystostomy may be performed under a local anaesthetic, which numbs your abdomen. This means you will be awake during the procedure.
The surgeon will use an ultrasound scan to guide a needle to the site of your gallbladder. The needle is then used to drain bile out of the gallbladder, which should help relieve inflammation (swelling). Once your symptoms improve, your gallbladder can be surgically removed.
Living without a gallbladder
You can lead a perfectly normal life without a gallbladder. The organ can be useful but it's not essential. Your liver will still produce bile to digest food.
However, some people who have had their gallbladder removed have reported symptoms of bloating and diarrhoea after eating fatty or spicy food. If certain foods do trigger symptoms, you may wish to avoid them in the future.
How to prevent acute cholecystitis
The most effective way of preventing acute cholecystitis is to reduce your risk of getting gallstones.
Many of the risk factors for gallstones, such as family history and being female, are unavoidable.
However, from the limited evidence available, the most effective way to prevent gallstones is to make lifestyle changes such as:
- making changes to your diet
- losing weight, if you are obese
These are described in more detail below.
Due to the role that cholesterol appears to play in the formation of gallstones, it is advisable to avoid eating fatty foods that have a high cholesterol content. Foods high in cholesterol include:
- meat pies
- sausages and fatty cuts of meat
- butter and lard
- cakes and biscuits
A low-fat, high-fibre diet is recommended. This includes eating wholegrains and at least five portions of fresh fruit and vegetables a day.
There is also evidence that regularly eating nuts, such as peanuts or cashew nuts, can help reduce the risk of developing gallstones, as can drinking alcohol in moderation (no more than three to four units a day for men and two to three units a day for women).
A unit of alcohol is equal to about half a pint of normal-strength lager, a small glass of wine or a pub measure (25ml) of spirits. Read more about alcohol and drinking.
Being overweight or obese increases the amount of cholesterol in your bile, which in turn increases your risk of developing gallstones. You can control your weight by eating a healthy diet and taking plenty of regular exercise.
However, avoid low-calorie diets that lead to rapid weight loss. There is evidence these can disrupt your bile chemistry and increase your risk of developing gallstones. A more gradual weight-loss plan is recommended.
Complications of acute cholecystitis
Gangrenous cholecystitis is a common complication of acute cholecystitis that occurs in up to 30% of cases. Gallbladder perforation is a less common but more serious complication that occurs in around 1 in 100 cases.
Gangrenous cholecystitis develops when severe inflammation (swelling) interrupts the blood supply to your gallbladder.
Without a constant supply of blood, the tissue of the gallbladder will begin to die. This is potentially serious because the dead tissue is vulnerable to serious infection, which can quickly spread throughout the body.
Known risk factors for gangrenous cholecystitis include:
- being male
- being 45 years of age or over
- having a history of diabetes
- having a history of heart disease
It is unclear why these risk factors make a person more vulnerable to gangrenous cholecystitis.
Other than a very rapid heartbeat (more than 90 beats a minute), gangrenous cholecystitis does not usually cause noticeable symptoms, so is usually diagnosed on the basis of test results.
Gangrenous cholecystitis would be strongly suspected if:
- your heart rate is more than 90 beats a minute
- you have a very high white blood cell count
- the ultrasound scan shows the wall of your gallbladder is thicker than 4.5mm
If gangrenous cholecystitis if suspected, a cholecystectomy will usually be carried out to remove the gallbladder as soon as possible.
In cases of severe inflammation, the wall of the gallbladder can tear and infected bile can leak out. This can cause an infection of the lining of the abdomen (tummy), known as peritonitis.
Symptoms of peritonitis include:
- a sudden and very severe abdominal pain
- a high temperature (fever) of 38ºC (100.4ºF) or above
- rapid heartbeat (tachycardia)
- feeling thirsty
- not passing urine or passing much less urine than normal
Peritonitis is treated using a combination of antibiotic injections and surgery to remove the gallbladder and drain away infected bile.
Read more information about peritonitis.