Acute Calculous Cholecystitis

Also known as: Cholecystitis

Acute calculous cholecystitis is acute inflammation of the gallbladder caused by persistent cystic duct obstruction by a gallstone.

Obstruction produces gallbladder distension, venous and lymphatic compromise, inflammatory injury and eventually secondary bacterial infection in some patients.

Progression can produce empyema, gangrenous cholecystitis, perforation, pericholecystic abscess or biliary peritonitis.

Definitive treatment in a surgically fit patient is early laparoscopic cholecystectomy during the same acute admission.

The typical presentation is persistent right upper quadrant or epigastric pain, usually lasting more than several hours, with nausea or vomiting.

Fever and local right upper quadrant tenderness are common.

Murphy sign: arrest of inspiration due to pain when the examiner palpates the right subcostal region during deep inspiration.

Older, diabetic and immunosuppressed patients may have limited fever or peritoneal signs despite advanced disease.

Severe persistent pain, high fever, sepsis or localised peritonism should raise concern for gangrene, empyema or perforation.

Jaundice requires assessment for common bile duct obstruction, Mirizzi syndrome or cholangitis.

Check full blood count, C reactive protein, renal function and liver biochemistry.

Leukocytosis and inflammatory marker elevation support the diagnosis but do not determine severity alone.

Right upper quadrant ultrasound: first line imaging; identify an obstructing gallstone with the key inflammatory features of gallbladder wall thickening, distension or pericholecystic inflammation.

If ultrasound is equivocal but clinical suspicion remains strong, hepatobiliary scintigraphy or cross sectional imaging can clarify the diagnosis.

Evaluate for common bile duct stones when bilirubin, alkaline phosphatase or duct calibre is abnormal.

Keep fasting initially, establish IV access and correct dehydration.

Provide adequate analgesia:

Paracetamol 1 g orally or IV every 6 to 8 hours, maximum 4 g daily in an adult without significant hepatic risk.

Add an NSAID when appropriate.

Start antimicrobial treatment for acute cholecystitis.

A practical community acquired regimen is:

Ceftriaxone 2 g IV every 24 hours.

Add:

Metronidazole 500 mg IV every 12 hours

when anaerobic coverage is clinically warranted, particularly with severe infection, perforation or altered biliary gastrointestinal anatomy.

For septic shock, gangrene, perforation or significant healthcare associated infection:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Definitive surgery

Perform laparoscopic cholecystectomy during the index admission and as early as clinically feasible after initial resuscitation. Early surgery reduces total hospitalisation and avoids recurrent gallstone complications without requiring an interval cooling off period.

During surgery, prioritise prevention of bile duct injury.

Achieve the critical view of safety before clipping or dividing structures.

If severe inflammation prevents safe identification:

Stop unsafe dissection
Consider a fundus first approach only when anatomy remains controllable
Perform subtotal cholecystectomy when necessary
Convert to open surgery when this improves safety, although conversion alone does not guarantee clearer anatomy

Subtotal cholecystectomy can be fenestrating or reconstituting according to anatomy and surgeon judgement.

High operative risk

A patient with severe acute illness who cannot safely undergo cholecystectomy may require percutaneous cholecystostomy for source control. Do not delay drainage simply to complete a prolonged failed conservative trial when the gallbladder remains the uncontrolled septic source.

Cholecystostomy is generally a bridge rather than definitive treatment in a patient who later becomes fit for cholecystectomy.

Antibiotic duration

After uncomplicated laparoscopic cholecystectomy for mild or moderate acute cholecystitis with satisfactory source control, routine postoperative antibiotics are unnecessary.

For severe cholecystitis with organ dysfunction or infection extending beyond the gallbladder, continue antibiotics according to clinical response, generally for no more than approximately 4 days after adequate source control.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Cholangiocarcinoma

Also known as: Bile duct cancer

Malignancy arising from the bile duct epithelium, classified by anatomical location as intrahepatic (arising within the liver parenchyma, increasingly grouped and managed alongside hepatocellular carcinoma given overlapping presentation), perihilar (Klatskin tumor, at the confluence of the right and left hepatic ducts, the most common location), and distal (extrahepatic, closer to the pancreatic head, sharing much of its clinical presentation and management pathway with pancreatic cancer).

Risk factors include primary sclerosing cholangitis (a major and well recognized association, see Ulcerative Colitis entry), liver fluke infection (Clostorchis sinensis and Opisthorchis viverrini, endemic in parts of Southeast Asia), choledochal cysts, hepatolithiasis, and chronic viral hepatitis.

Perihilar and distal tumors present similarly to pancreatic head cancer: painless, progressive obstructive jaundice, pale stools and dark urine, pruritus from cholestasis, and weight loss. Intrahepatic cholangiocarcinoma more often presents with nonspecific abdominal pain, weight loss, and a hepatic mass detected on imaging, since jaundice only occurs late once major ducts are compressed. Fever suggests superimposed cholangitis from biliary obstruction, and should be actively assessed for given the need for urgent drainage if present (see Cholangitis entry).

LFTs show a cholestatic pattern. CA19-9 is used as a tumor marker to support diagnosis and monitor treatment response, though it lacks the sensitivity and specificity to be diagnostic alone, and can be markedly elevated by biliary obstruction of any cause including benign disease. Cross sectional imaging with contrast enhanced CT or MRI with MRCP characterizes the tumor, its relationship to the biliary tree and vasculature, and assists staging. ERCP or percutaneous transhepatic cholangiography allows tissue sampling (brushings or biopsy, though sensitivity is limited given the typically desmoplastic, hypocellular nature of these tumors) and, importantly, therapeutic biliary drainage. PET CT and staging laparoscopy assess for occult metastatic or peritoneal disease prior to considering resection.

Differentials include pancreatic cancer (for distal tumors), benign biliary stricture (particularly in the context of primary sclerosing cholangitis, where distinguishing benign dominant stricture from malignant transformation can be genuinely difficult and requires close surveillance), hepatocellular carcinoma (for intrahepatic tumors), and other periampullary malignancy.

Resectable disease is treated with surgical resection tailored to tumor location: major hepatectomy with extrahepatic bile duct resection for perihilar tumors, pancreaticoduodenectomy for distal tumors (following the same principles as for pancreatic cancer), and hepatic resection for intrahepatic tumors, followed by adjuvant chemotherapy (commonly capecitabine). Liver transplantation, combined with neoadjuvant chemoradiotherapy under a strict protocol, is an option for carefully selected perihilar cholangiocarcinoma at specialist centers. Unresectable or metastatic disease is managed with palliative chemotherapy (gemcitabine and cisplatin is the standard first-line combination), with targeted therapy increasingly available for tumors harboring specific molecular alterations (FGFR2 fusions, IDH1 mutations) identified on molecular profiling. Biliary decompression, whether by ERCP stenting or percutaneous transhepatic drainage, is a central component of management at every stage, both to relieve symptomatic jaundice and pruritus and to permit safe delivery of chemotherapy in patients with obstructive jaundice.

Referral: hepatobiliary surgery and oncology multidisciplinary team for all confirmed or suspected cases; gastroenterology for biliary drainage and tissue sampling.

Acute Calculous Cholecystitis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management