Cholecystitis is inflammation of the gallbladder, a small organ located beneath the liver. The condition often develops when a gallstone blocks the cystic duct, preventing bile from leaving the gallbladder. Trapped bile increases pressure inside the organ, irritates its wall and may lead to swelling, reduced blood flow and infection.
The most common symptom is severe, steady pain in the right upper quadrant, or RUQ, of the abdomen. Pain may also occur in the upper middle abdomen and spread toward the right shoulder blade or back. Nausea, vomiting, fever, bloating, tenderness and a positive Murphy’s sign are also common. Symptoms often become more noticeable after a fatty meal because eating causes the gallbladder to contract.
Cholecystitis requires prompt assessment. Untreated inflammation may progress to gallbladder gangrene, perforation, abscess formation, peritonitis or sepsis. A stone entering the common bile duct may also cause jaundice, cholangitis or gallstone pancreatitis.
Diagnosis usually combines symptoms, physical findings, blood tests and imaging. Abdominal ultrasound is generally the first imaging test. A HIDA scan, CT scan, MRI or MRCP may provide more information when the diagnosis remains unclear.
What Is Cholecystitis?
Cholecystitis means inflammation and irritation of the gallbladder. It may appear suddenly as acute cholecystitis or develop gradually through repeated episodes of inflammation.
Meaning of the Word Cholecystitis
| Word Part | Meaning |
|---|---|
| Chole | Bile |
| Cyst | Sac or bladder |
| Itis | Inflammation |
The term therefore describes inflammation of the bile-storing sac, or gallbladder.
What Does the Gallbladder Do?
The liver continuously produces bile, a digestive fluid containing bile acids, cholesterol, bilirubin and other substances. The gallbladder stores and concentrates bile between meals.
After food enters the small intestine, the gallbladder contracts and releases bile through the bile ducts. Bile supports fat digestion and helps the liver remove bilirubin and other waste products.
How Cholecystitis Develops
Acute calculous cholecystitis usually develops through the following sequence:
- A gallstone enters or presses against the cystic duct.
- The cystic duct becomes blocked.
- Bile remains trapped inside the gallbladder.
- Pressure and chemical irritation inflame the gallbladder wall.
- Reduced blood flow and bacterial infection may follow.
Persistent obstruction can damage gallbladder tissue. Severe inflammation may produce pus, tissue death or a hole in the gallbladder wall.
Types of Cholecystitis
Cholecystitis is classified according to its cause and duration.
| Type | Main Cause | Typical Features |
| Acute calculous cholecystitis | Gallstone blocking the cystic duct | Sudden RUQ pain, fever, nausea and tenderness |
| Acute acalculous cholecystitis | Inflammation without gallstones | More common during critical illness or severe systemic disease |
| Chronic cholecystitis | Repeated irritation and inflammation | Recurrent pain, thickened gallbladder and reduced function |
| Gangrenous cholecystitis | Severe inflammation with tissue death | Higher risk of perforation and sepsis |
| Emphysematous cholecystitis | Gas-forming infection in the gallbladder | Severe infection, often in high-risk patients |
Acute Calculous Cholecystitis
This is the most common form. A gallstone blocks the cystic duct, causing bile retention and inflammation.
Pain is generally constant rather than intermittent. Fever, leukocytosis and gallbladder tenderness may develop as inflammation progresses.
Acalculous Cholecystitis
Acalculous cholecystitis occurs without gallstones. It is associated with severe illness, major surgery, trauma, sepsis, prolonged fasting and impaired gallbladder blood flow or emptying.
Symptoms may be difficult to recognize in unconscious, ventilated or critically ill patients. Acalculous disease may progress rapidly and needs urgent treatment.
Chronic Cholecystitis
Chronic cholecystitis develops after repeated gallstone attacks or long-term irritation. The gallbladder wall becomes thick, scarred and less able to store or release bile.
Patients may experience recurring upper abdominal discomfort, nausea or pain after meals. Chronic symptoms are often less dramatic than acute inflammation.
Cholecystitis vs Other Gallbladder Conditions
Gallstones may affect different sections of the biliary system. The location and duration of obstruction determine the condition that develops.
| Condition | Main Problem | Typical Presentation |
| Cholelithiasis | Stones inside the gallbladder | Often asymptomatic |
| Biliary colic | Temporary cystic duct obstruction | Episodic pain without persistent inflammation |
| Cholecystitis | Inflamed gallbladder | Persistent RUQ pain, fever and tenderness |
| Choledocholithiasis | Stone in the common bile duct | Jaundice, abnormal liver tests or pain |
| Cholangitis | Infection of obstructed bile ducts | RUQ pain, fever, chills and jaundice |
| Gallstone pancreatitis | Stone blocks pancreatic drainage | Severe upper abdominal pain and raised lipase |
Silent gallstones do not normally require treatment. Once stones cause pain, inflammation, duct obstruction or pancreatitis, medical or surgical treatment becomes necessary.
Causes and Risk Factors
Gallstones as the Main Cause
The most common cause of acute cholecystitis is a gallstone obstructing the cystic duct. Gallstones may form when bile contains too much cholesterol or bilirubin, too few bile salts, or when the gallbladder does not empty properly.
Less common causes include:
- Gallbladder tumors
- Bile duct narrowing
- Reduced gallbladder blood supply
- Severe systemic infection
- Prolonged fasting
- Critical illness
- Major trauma or surgery
The 5 F’s of Gallstone Risk
A traditional study mnemonic identifies five common gallstone risk factors:
- Family history
- Female sex
- Fat, referring to overweight or obesity
- Forty or older
- Fertile, referring to pregnancy or estrogen exposure
The 5 F’s are a memory aid, not diagnostic criteria. Gallstones also affect people who do not match this description.
Additional Risk Factors
Risk may increase with:
- Obesity
- Pregnancy
- Older age
- Diabetes
- Hormone therapy
- Rapid weight loss
- Weight cycling
- Bariatric surgery
- Low-fibre, high-calorie eating patterns
- Certain blood disorders
- Family or genetic susceptibility
Obesity raises cholesterol levels in bile, while rapid weight loss releases additional cholesterol and may reduce normal gallbladder emptying.
Symptoms of Cholecystitis
Right Upper Quadrant Pain
The main symptom is severe pain in the right upper abdomen or epigastric area. The pain is usually steady and may last for several hours.
It may:
- Spread to the right shoulder blade or back
- Become worse during deep breathing
- Start after a heavy or fatty meal
- Increase when the RUQ is touched
- Occur with guarding or abdominal stiffness
Nausea, vomiting, fever, loss of appetite and bloating commonly accompany the pain.
Murphy’s Sign
A positive Murphy’s sign supports suspected acute cholecystitis.
During the test, a clinician presses beneath the right rib margin while the patient takes a deep breath. Inspiration suddenly stops because the inflamed gallbladder moves downward and touches the examiner’s hand, causing pain.
Murphy’s sign should not be used alone. Current diagnostic guidance recommends combining physical findings with inflammatory markers and imaging.
Common Symptoms and Findings
- Severe RUQ or epigastric pain
- Nausea and vomiting
- Fever or chills
- Loss of appetite
- Abdominal bloating
- RUQ tenderness
- Positive Murphy’s sign
- Tachycardia
- Elevated white blood cell count
- Raised C-reactive protein
Signs of Biliary Obstruction
The cystic duct drains only the gallbladder. Jaundice and major liver-test abnormalities may indicate that a stone has entered the common bile duct.
Warning signs include:
- Yellow skin or eyes
- Dark or tea-coloured urine
- Pale or clay-coloured stool
- Generalized itching
- Raised bilirubin
- Raised alkaline phosphatase
- Elevated AST or ALT
Bile duct obstruction can lead to cholangitis and requires urgent assessment.
Biliary Colic vs Acute Cholecystitis
| Feature | Biliary Colic | Acute Cholecystitis |
| Obstruction | Usually temporary | Persistent |
| Pain | Episodic and often resolves | Continuous and prolonged |
| Fever | Usually absent | May be present |
| Inflammation markers | Usually normal | Often elevated |
| Murphy’s sign | Usually absent | May be positive |
| Gallbladder wall inflammation | Absent | Present |
Diagnosis of Cholecystitis
No single symptom, examination finding or laboratory value confirms acute cholecystitis. Diagnosis uses a combination of clinical history, physical examination, blood tests and imaging.
Blood Tests
Common investigations include:
- Complete blood count
- C-reactive protein
- Bilirubin
- Alkaline phosphatase
- AST and ALT
- Amylase and lipase
- Kidney function tests
- Electrolytes
- Blood cultures when sepsis is suspected
White blood cells and CRP may rise because of inflammation. Bilirubin and liver enzymes help identify possible common bile duct obstruction. Lipase helps assess for gallstone pancreatitis.
Imaging Tests
Abdominal Ultrasound
Right upper quadrant ultrasound is usually the first imaging test. It is widely available, does not use ionizing radiation and shows both the gallbladder and bile ducts.
Ultrasound may identify:
- Gallstones
- Thickened gallbladder wall
- Enlarged gallbladder
- Pericholecystic fluid
- Impacted cystic duct stone
- Sonographic Murphy’s sign
- Common bile duct enlargement
Ultrasound is the preferred initial study for suspected acute cholecystitis.
HIDA Scan
A HIDA scan, also called hepatobiliary cholescintigraphy, follows a radioactive tracer as it moves through the liver and biliary system.
Failure to visualize the gallbladder suggests cystic duct obstruction. HIDA scanning is useful when symptoms strongly suggest cholecystitis but ultrasound results are negative or uncertain.
CT Scan, MRI and MRCP
A CT scan may identify perforation, abscess, gas, tissue death or another cause of abdominal pain. MRI and MRCP provide detailed views of the gallbladder and bile ducts without inserting an endoscope.
These tests are often used when ultrasound findings are unclear or a common bile duct stone is suspected.
ERCP
Endoscopic retrograde cholangiopancreatography, or ERCP, combines endoscopy and X-ray imaging. It allows a clinician to enter the bile duct, remove common bile duct stones and place a stent when required.
ERCP is not the routine first test for uncomplicated cholecystitis. It is mainly used when choledocholithiasis or cholangitis is suspected.
Tokyo Diagnostic Criteria
The Tokyo Guidelines organize diagnosis into three categories.
| Category | Findings |
| Local inflammation | Murphy’s sign, RUQ pain, tenderness or mass |
| Systemic inflammation | Fever, elevated WBC or elevated CRP |
| Imaging | Findings characteristic of acute cholecystitis |
A suspected diagnosis requires local and systemic signs. Imaging confirms the clinical diagnosis.
Severity Grades
| Grade | Meaning |
| Grade I, mild | No organ dysfunction and limited local inflammation |
| Grade II, moderate | Marked local inflammation or features suggesting difficult surgery |
| Grade III, severe | Cardiovascular, respiratory, neurological, renal, liver or blood-clotting dysfunction |
Severity grading helps clinicians decide whether a patient needs immediate surgery, intensive monitoring, gallbladder drainage or critical care.
Treatment of Cholecystitis
Treatment aims to control pain and infection, restore hydration, remove the obstruction and prevent recurrence.
Initial Hospital Treatment
Initial management commonly includes:
- Keeping the patient NPO
- Intravenous fluids
- Electrolyte correction
- Pain medicine
- Antiemetic medicine
- Antibiotics when infection is suspected
- Monitoring vital signs and urine output
- Surgical assessment
NPO status reduces gallbladder stimulation and prepares the patient for possible surgery. Antibiotic selection depends on disease severity, organ function, allergy history and local resistance patterns.
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy removes the gallbladder through several small abdominal incisions. It is the first-line definitive treatment for most patients who are fit for surgery.
Guidelines favour early surgery. WSES recommends operating as soon as possible, generally within seven days of hospital admission and within ten days of symptom onset. NICE recommends laparoscopic cholecystectomy within one week of diagnosis.
Early surgery reduces recurrent attacks and avoids another hospital admission while waiting for delayed treatment.
Open Cholecystectomy
Open surgery may be required when:
- Inflammation is severe
- Anatomy cannot be identified safely
- Significant bleeding occurs
- A bile duct injury is suspected
- Dense adhesions prevent safe laparoscopic surgery
Conversion from laparoscopic to open surgery is a safety decision, not a treatment failure.
ERCP for Common Bile Duct Stones
ERCP may be performed before, during or after cholecystectomy when a stone is present in the common bile duct.
The procedure may:
- Remove duct stones
- Drain infected bile
- Relieve jaundice
- Insert a biliary stent
- Treat acute cholangitis
ERCP treats stones in the bile duct. It does not remove the gallbladder or prevent new gallbladder stones from causing future attacks.
Percutaneous Cholecystostomy
Percutaneous cholecystostomy places a drainage tube through the skin into the gallbladder.
It may be used when severe infection is present and surgery is temporarily unsafe. The patient may later undergo cholecystectomy after stabilization.
T-Tube Drainage
A T-tube may occasionally be placed in the common bile duct after surgical bile duct exploration. It drains bile externally while the duct heals.
T-tubes are not routinely used after standard laparoscopic gallbladder removal. Their use depends on the procedure and surgical findings.
Lithotripsy and Stone-Dissolving Medicines
Shock-wave lithotripsy and bile-acid medicines are uncommon treatments for selected cholesterol stones. They act slowly, stones may return and they are not standard treatment for acute cholecystitis.
Surgery remains the usual treatment for symptomatic gallstones and gallstone-related inflammation.
Nursing Interventions for Cholecystitis
Initial Nursing Assessment
The nurse should assess:
- Pain location, severity and duration
- Relationship between pain and meals
- Nausea and vomiting
- Temperature and heart rate
- Blood pressure and respiratory status
- Abdominal tenderness and guarding
- Skin and eye colour
- Urine and stool colour
- Hydration status
- Mental status
- Laboratory and imaging results
Increasing pain, hypotension, confusion, oliguria or a rising temperature may indicate worsening infection or sepsis.
Preoperative Nursing Care
Important interventions include:
- Maintain NPO status
- Administer IV fluids as prescribed
- Monitor fluid balance and electrolytes
- Give analgesics and antiemetics
- Administer antibiotics on schedule
- Monitor vital signs
- Prepare the patient for surgery
- Explain deep-breathing and mobility exercises
- Verify consent and preoperative requirements
An NG tube is not required for every patient. It may be ordered for persistent vomiting, gastric distension, ileus or specific surgical indications.
Postoperative Nursing Care
After cholecystectomy:
- Monitor airway, breathing and circulation
- Assess incision sites
- Monitor pain and nausea
- Encourage deep breathing
- Promote early mobilization
- Observe for bleeding or bile leakage
- Advance the diet as prescribed
- Monitor urine output
- Watch for jaundice, fever or worsening abdominal pain
Some patients develop temporary shoulder discomfort from laparoscopic gas. Loose stools may also occur for several weeks as digestion adjusts.
T-Tube Nursing Care
When a T-tube is present:
- Keep the drainage bag below abdominal level
- Prevent twisting, pulling or kinking
- Record drainage amount and colour
- Inspect the skin around the tube
- Maintain the prescribed drainage system
- Do not clamp or flush without an order
- Report sudden loss of drainage
- Report a major increase in bloody or foul drainage
Diet for Cholecystitis
During an acute episode, the patient may remain NPO until pain, vomiting and inflammation improve.
Once oral intake resumes, smaller low-fat meals may reduce gallbladder stimulation and discomfort.
| Choose More Often | Limit While Symptomatic |
| Oats and whole grains | Fried foods |
| Fruits and vegetables | Fatty meat |
| Beans and lentils | Cream and full-fat dairy |
| Lean poultry or fish | Butter and ghee |
| Low-fat dairy | Fast food |
| Smaller meals | Large heavy meals |
Avoiding all fat indefinitely is unnecessary. The body needs healthy fats, and the liver continues producing bile after gallbladder removal.
Most people live normally without a gallbladder because bile continues to reach the small intestine through the bile ducts.
Complications of Cholecystitis
Untreated or severe cholecystitis may cause:
- Gallbladder empyema
- Gangrenous cholecystitis
- Gallbladder perforation
- Pericholecystic abscess
- Bile peritonitis
- Sepsis
- Common bile duct obstruction
- Acute cholangitis
- Gallstone pancreatitis
- Biliary fistula
Gangrene and perforation allow infected bile to spread into surrounding tissues or the abdominal cavity. These complications require urgent drainage or surgery.
When to Seek Emergency Care
Seek urgent medical care for:
- Severe or persistent RUQ pain
- Pain lasting several hours
- Fever or shaking chills
- Repeated vomiting
- Yellow skin or eyes
- Dark urine or pale stool
- Confusion
- Fainting or low blood pressure
- Rapid breathing
- A rigid or swollen abdomen
Pain, fever and jaundice together may indicate acute cholangitis. This condition can progress rapidly to sepsis.
Important Clinical Clarifications
The source infographic provides useful study points, but several treatments apply only in selected clinical situations.
| Infographic Point | Current Clinical Context |
| ERCP removes gallstones | ERCP mainly removes stones from the common bile duct, not stones remaining inside the gallbladder. |
| T-tube drains bile | Correct, but T-tubes are now used selectively after bile duct procedures, not routinely after cholecystectomy. |
| Lithotripsy breaks up stones | Correct, but gallstone lithotripsy is uncommon and is not standard acute cholecystitis treatment. |
| NG tube insertion | Gastric decompression may help selected patients, but an NG tube is not routine for every case. |
| No fatty foods | Fatty meals may worsen symptoms. A temporary low-fat pattern is useful, but permanent complete fat avoidance is unnecessary. |
| Cholecystitis may lead to hepatitis | Liver enzymes may rise with biliary obstruction. Acute hepatitis is more often an alternative diagnosis, while recognized direct complications include gangrene, perforation, abscess, peritonitis and sepsis. |
Cholecystitis Quick Review
| Topic | Key Point |
| Definition | Inflammation of the gallbladder |
| Main cause | Gallstone blocking the cystic duct |
| Classic pain | Steady RUQ pain, often after a fatty meal |
| Examination sign | Positive Murphy’s sign |
| First imaging test | Abdominal ultrasound |
| Follow-up imaging | HIDA scan, CT, MRI or MRCP |
| Definitive treatment | Early laparoscopic cholecystectomy |
| ERCP role | Removes common bile duct stones |
| Major danger | Gangrene, perforation and sepsis |
| Nursing priorities | NPO, IV fluids, pain control, monitoring and surgical preparation |
FAQs
1. What is the main cause of cholecystitis?
The main cause is a gallstone blocking the cystic duct. The blockage traps bile inside the gallbladder and increases pressure against its wall. Continued obstruction causes inflammation and may lead to infection or tissue damage.
2. What does cholecystitis pain feel like?
Pain is usually severe, steady and located in the right upper or upper middle abdomen. It may spread toward the right shoulder blade or back. The pain often lasts several hours and may worsen after a fatty meal or during deep breathing.
3. What is a positive Murphy’s sign?
A positive Murphy’s sign occurs when a person suddenly stops inhaling because of pain while the examiner presses beneath the right rib margin. It suggests irritation around the gallbladder. The finding supports cholecystitis but must be combined with laboratory and imaging results.
4. What is the difference between gallstones and cholecystitis?
Gallstones are solid particles inside the gallbladder or bile ducts. Many gallstones remain silent and cause no inflammation. Cholecystitis develops when obstruction or another process causes the gallbladder itself to become inflamed.
5. Which test is best for cholecystitis?
Abdominal ultrasound is usually the first imaging test. It may show gallstones, gallbladder wall thickening, enlargement and surrounding fluid. A HIDA scan is useful when ultrasound results are uncertain but clinical suspicion remains high.
6. Does cholecystitis always require surgery?
Most patients with acute calculous cholecystitis who are fit for surgery receive laparoscopic cholecystectomy. Some patients need temporary medical treatment or gallbladder drainage before surgery. The treatment plan depends on severity, organ function and surgical risk.
7. Why are patients kept NPO with cholecystitis?
Eating stimulates the gallbladder to contract and release bile. Contraction against a blocked cystic duct may worsen pain and pressure. NPO status also prepares the patient for anesthesia, imaging or urgent surgery.
8. When is ERCP used for cholecystitis?
ERCP is used when a stone is suspected or confirmed in the common bile duct. It may remove the stone, drain infected bile or place a stent. ERCP is not usually required for uncomplicated cystic duct obstruction without common bile duct involvement.
9. What foods should be avoided during cholecystitis?
Fried foods, fatty meats, butter, cream and large high-fat meals may trigger or worsen pain. Smaller meals with lean protein, fruits, vegetables and whole grains are often better tolerated. Dietary changes manage symptoms but do not remove an obstructing gallstone.
10. Can cholecystitis become life-threatening?
Severe cholecystitis may cause tissue death, perforation, abscess, peritonitis or sepsis. A stone in the common bile duct may also lead to cholangitis or pancreatitis. Persistent pain with fever, jaundice, confusion or low blood pressure needs emergency assessment.
