Medically reviewed by Prof. Dr. Zahid Mahmood, MBBS, FCPS — General, Laparoscopic & Laser Surgeon, Lahore.
Acute cholecystitis is sudden inflammation of the gallbladder, usually caused by a gallstone blocking its outlet. It typically produces persistent pain in the upper-right abdomen, tenderness, nausea and fever. Unlike a brief attack of biliary colic, the pain and inflammation do not quickly settle when the stone remains impacted.
This condition needs prompt medical assessment. Untreated inflammation can progress to pus inside the gallbladder, tissue death, perforation, abdominal infection or sepsis. Early treatment and, for most suitable patients, laparoscopic removal of the gallbladder provide definitive care.
What does the gallbladder do?
The gallbladder is a small sac beneath the liver. It stores and concentrates bile made by the liver, then releases it through the bile ducts into the small intestine to help digest fat. A person can live normally without a gallbladder because bile continues to flow directly from the liver into the intestine.
What causes acute cholecystitis?
In approximately 90–95% of cases, a gallstone or thick biliary sludge becomes lodged in the cystic duct—the narrow channel draining the gallbladder. Trapped bile increases pressure, stretches the wall and triggers inflammation. Reduced blood flow and secondary bacterial infection may make the disease more severe.
Less commonly, acute acalculous cholecystitis occurs without stones. It is mainly seen in people who are critically ill, have had major surgery or trauma, have severe burns, sepsis or prolonged fasting, or require intensive care. It can progress rapidly and may be difficult to recognise.
Symptoms of acute cholecystitis
Common symptoms include:
- Persistent pain in the upper-right abdomen or upper-middle abdomen
- Pain spreading to the right shoulder blade or back
- Marked tenderness beneath the right ribs
- Fever or chills
- Nausea, vomiting and loss of appetite
- Pain that becomes worse with a deep breath or movement
- Abdominal bloating and a general feeling of illness
Symptoms may begin after a meal, particularly a heavy or fatty meal, but this is not always the case. Older adults, people with diabetes and immunocompromised patients may have less obvious pain or fever despite serious disease.
Acute cholecystitis or biliary colic?
Biliary colic occurs when a stone temporarily blocks the gallbladder outlet and then moves. The pain can be severe but usually settles within several hours, and fever or marked inflammatory signs are absent.
In acute cholecystitis, obstruction persists and the gallbladder wall becomes inflamed. Pain is sustained—commonly longer than six hours—and is accompanied by localised tenderness, fever or raised inflammatory markers. The distinction requires clinical assessment; patients should not try to time the pain at home while becoming increasingly unwell.
When should you go to hospital?
Seek urgent medical assessment for severe or persistent upper-abdominal pain, particularly when it lasts several hours or occurs with fever, repeated vomiting or tenderness under the right ribs.
Go to an emergency department immediately if there is:
- Yellowing of the eyes or skin, dark urine or pale stools
- High fever, shaking chills or confusion
- Fainting, severe weakness, rapid heartbeat or breathing difficulty
- A rigid or increasingly swollen abdomen
- Pain spreading across the abdomen or suddenly becoming much worse
- Inability to keep fluids down or reduced urine output
Jaundice with fever and upper-abdominal pain can indicate acute cholangitis—an infected, obstructed main bile duct—which may require emergency drainage by ERCP.
How is acute cholecystitis diagnosed?
The diagnosis combines symptoms, examination, blood tests and imaging. No single symptom or test should be interpreted alone.
On examination, pressing beneath the right rib margin while the patient breathes in may produce sudden pain and interruption of inspiration. This is called Murphy’s sign. The clinician also checks temperature, pulse, blood pressure, hydration, jaundice and signs of sepsis or peritonitis.
Blood tests
Tests commonly include:
- Full blood count and C-reactive protein: assess inflammation and infection.
- Liver function tests: jaundice or abnormal results may suggest a stone in the common bile duct or another liver/biliary problem.
- Amylase or lipase: helps identify gallstone pancreatitis.
- Kidney function, electrolytes, glucose and clotting: guide fluid treatment and preparation for surgery.
- Blood cultures: may be taken when fever, sepsis or bloodstream infection is suspected.
Normal liver tests do not exclude acute cholecystitis because the blockage is usually in the cystic duct rather than the main bile duct.
Ultrasound and other imaging
Ultrasound is usually the first imaging test. It can show gallstones or sludge, a thickened gallbladder wall, fluid around the gallbladder, distension and tenderness when the probe presses over it. Ultrasound also examines the common bile duct for dilatation.
If ultrasound is inconclusive but suspicion remains, a hepatobiliary scan (HIDA scan) may show failure of the gallbladder to fill. CT scanning is useful when complications such as perforation, gangrene or abscess are suspected or another diagnosis is possible. MRCP or endoscopic ultrasound may be used when a common bile duct stone is suspected.
What else can cause similar pain?
Conditions that can resemble acute cholecystitis include pancreatitis, a perforated peptic ulcer, hepatitis, appendicitis in an unusual position, right-sided kidney infection or stone, lower-lobe pneumonia and even a heart attack. This is why persistent upper-abdominal pain should not be diagnosed from symptoms alone.
Initial treatment in hospital
Initial care usually includes:
- Temporary fasting while the diagnosis and treatment plan are established
- Intravenous fluids to correct dehydration
- Appropriate pain relief and anti-sickness medicine
- Antibiotics when infection is suspected or according to severity and local policy
- Monitoring of vital signs, urine output and blood results
- Assessment by a surgical team
Antibiotic choice depends on illness severity, allergies, kidney and liver function, local resistance patterns and whether infection is community- or hospital-acquired. Patients should not start leftover antibiotics at home.
Why are antibiotics alone usually not a permanent cure?
Fluids, pain relief and antibiotics may control the acute inflammation, but they do not remove the gallstones or the diseased gallbladder. Without definitive treatment, another painful episode or a complication can occur. For patients fit for surgery, gallbladder removal is therefore usually recommended during the same hospital admission or early after diagnosis.
Early laparoscopic cholecystectomy
Laparoscopic cholecystectomy is keyhole surgery to remove the gallbladder. Current guidance supports early surgery—during the acute admission and, where feasible, within one week of diagnosis—because it treats the source, shortens the total period of illness and reduces recurrent attacks while waiting.
Under general anaesthesia, the surgeon places a camera and instruments through several small abdominal incisions. The cystic duct and artery are carefully identified, clipped and divided, and the gallbladder is separated from the liver and removed.
The exact timing depends on disease severity, duration of symptoms, the patient’s fitness, possible bile-duct stones and the availability of an experienced surgical team. Severe inflammation can make dissection more difficult, but this does not automatically mean surgery should be delayed.
Can keyhole surgery become open surgery?
Yes. If anatomy cannot be identified safely because of severe inflammation, scarring, bleeding or an unexpected finding, the surgeon may make a larger incision or use another “bail-out” procedure. Conversion is a safety decision, not a failure.
In selected difficult cases, the surgeon may perform a subtotal cholecystectomy, leaving a small portion of the gallbladder wall rather than risking injury to the main bile duct or nearby vessels.
What if a common bile duct stone is present?
A stone may pass from the gallbladder into the common bile duct, causing jaundice, cholangitis or pancreatitis. Further imaging may be needed. The stone can be removed by:
- ERCP: a flexible camera is passed through the mouth to the duodenum, where the bile-duct opening is treated and the stone extracted.
- Laparoscopic bile-duct exploration: the surgeon removes the stone during the gallbladder operation in centres with appropriate expertise.
ERCP treats the bile duct but does not remove the gallbladder, so cholecystectomy is still usually required when the patient is suitable.
Gallbladder drainage for high-risk patients
Some patients are temporarily too unwell for general anaesthesia because of severe sepsis, organ failure or major medical problems. A radiologist may place a tube through the skin into the gallbladder to drain infected fluid. This is called percutaneous cholecystostomy.
Drainage can control sepsis while the patient recovers, but it is not always the final treatment. Suitability for later cholecystectomy should be reassessed once the medical condition improves.
Possible complications of acute cholecystitis
Complications include:
- Empyema: pus collecting inside the gallbladder
- Gangrenous cholecystitis: death of part of the gallbladder wall
- Perforation: rupture causing a local abscess or widespread peritonitis
- Emphysematous cholecystitis: gas-forming infection, particularly dangerous in people with diabetes
- Sepsis and organ dysfunction
- Obstructive jaundice, cholangitis or gallstone pancreatitis
- Gallstone ileus: rare bowel obstruction after a large stone passes through an abnormal connection to the intestine
Risks of gallbladder surgery
Laparoscopic cholecystectomy is common and usually safe, but possible complications include bleeding, wound or abdominal infection, blood clots, chest complications, bile leakage, retained bile-duct stones and injury to the common bile duct, bowel or blood vessels. Some complications require endoscopy, radiological drainage or further surgery.
Risk varies with age, obesity, diabetes, heart or lung disease, previous operations and the severity of inflammation. Individual risks should be discussed during consent.
Recovery after laparoscopic cholecystectomy
Many patients begin drinking and eating as tolerated soon after surgery. Hospital stay depends on the severity of infection and operation; uncomplicated patients may go home the same day or after one night, whereas complex cases need longer observation.
Shoulder-tip discomfort from the gas used during laparoscopy, mild abdominal soreness, bruising and tiredness are common for several days. Walking is encouraged. Return to driving, work and exercise depends on pain control, movement, the type of work and the surgeon’s advice.
A special long-term diet is usually unnecessary. Smaller, lower-fat meals may be more comfortable initially, followed by gradual return to a balanced normal diet. A minority of patients experience temporary loose stools or food sensitivity.
Warning signs after discharge
Contact the surgical team or seek urgent care for:
- Increasing or severe abdominal pain
- Fever, chills or worsening weakness
- Persistent vomiting or inability to drink
- Yellow eyes or skin, dark urine or pale stools
- A swollen abdomen or breathing difficulty
- Redness, pus or increasing swelling at a wound
- Calf pain or swelling, chest pain or sudden shortness of breath
Can acute cholecystitis be prevented?
Not every episode is preventable. Maintaining a healthy weight, avoiding crash diets and following a balanced diet may reduce gallstone risk. Once gallstones are causing symptoms, diet may reduce triggers but cannot dissolve established stones or guarantee prevention of cholecystitis. Planned surgery for symptomatic stones can prevent future gallbladder attacks.
Common questions
Is acute cholecystitis an emergency?
It is an urgent surgical condition. Many patients are stable after initial treatment, but complications can develop, so prompt hospital assessment is important.
Can acute cholecystitis settle without surgery?
The immediate inflammation may settle with supportive care and antibiotics, but the gallstones remain and symptoms can recur. Most suitable patients are advised to have the gallbladder removed.
Can I live normally without a gallbladder?
Yes. The liver continues to make bile, which flows directly into the intestine. Most people return to a normal diet and activities after recovery.
Does every gallstone cause acute cholecystitis?
No. Many gallstones never cause symptoms. Acute cholecystitis develops when a stone or sludge obstructs the gallbladder outlet and triggers sustained inflammation.
Will removing only the stones solve the problem?
Usually not. Stones commonly reform because the gallbladder remains. Standard definitive treatment is removal of the gallbladder, not simply taking stones out of it.
Key message
Persistent upper-right abdominal pain with tenderness, fever, nausea or vomiting may be acute cholecystitis and needs prompt assessment. Ultrasound and blood tests confirm the diagnosis, while early laparoscopic cholecystectomy provides definitive treatment for most suitable patients. Delaying care increases the risk of infection, gangrene, perforation and sepsis.
Medical references
- O’Connell PR, McCaskie AW, Sayers RD, editors. Bailey & Love’s Short Practice of Surgery. 28th ed. Chapter 71: The gallbladder and bile ducts, pp. 1244–1245.
- National Institute for Health and Care Excellence. Gallstone disease: diagnosis and management (CG188).
- World Society of Emergency Surgery. 2020 updated guidelines for the diagnosis and treatment of acute calculous cholecystitis.
- Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:41–54.
This article provides general education and does not replace an examination or individual medical advice. Seek urgent hospital care for persistent severe abdominal pain, fever, jaundice, confusion, fainting or repeated vomiting.