Patients with acute cholecystitis usually present with the following symptoms:

• Pain: Patients with cholecystitis usually present with right upper quadrant pain which radiates to the tip of right shoulder. There may be tenderness in right hypochondrium.
• Symptoms typically start after eating.
  Fever: Patient may present with fever and possibly chills [5].
• Jaundice: Mild jaundice with dark urine and pale stools may also be present.
• Other symptoms: These include anorexia, nausea, vomiting, sweating and abdominal bloating.
• More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, ascending cholangitis or perforation. Sepsis or pancreatitis may also develop [6].

• Chills

  Symptomatology: —Among the first symptoms are chill and fever. Usually the fever does not exceed 101.5° or 102° F., except in the suppurative forms, when it becomes remittent in character, and in the exacerbations may reach 104° or 104.5° F. [henriettes-herb.com]

  Chills. Bloating. Jaundice (yellowing of the skin and eyes). Cleveland Clinic News & More Cleveland Clinic News & More [my.clevelandclinic.org]

  The patient also experiences nausea, vomiting, and chills. In chronic cholecystitis the gallbladder often is contracted rather than swollen; its wall is grayish white, tough, and thickened. [britannica.com]

  Symptoms The symptoms for acute gallstone cholecystitis are: abdominal pain located in the right or on the upper part of the abdomen, a pain that increases with increased heart rate; fever and chills; loss of appetite; nausea and / or vomiting. [health.ccm.net]

• Nausea

  The antibiotics are intended to treat the infection, and other medications are given to combat nausea and pain. Once pain and infection are gone, you can return back home to continue with your daily life. [belmarrahealth.com]

  The patient also experiences nausea, vomiting, and chills. In chronic cholecystitis the gallbladder often is contracted rather than swollen; its wall is grayish white, tough, and thickened. [britannica.com]

  Symptoms of chronic cholecystitis include abdominal pain, indigestion, nausea and excess belching. [ddc.musc.edu]

  Signs and symptoms of cholecystitis include upper GI pain (epigastric) that travels to the right shoulder blade (this pain tends to increase after a heavy greasy/fatty/spicy meal), positive Murphy's Sign, nausea, vomiting, steatorrhea, fever, and tachycardia [youtube.com]

  Gastric decompression to reduce stimulation of the gallbladder may be indicated for control of severe nausea and vomiting. [medical-dictionary.thefreedictionary.com]

• Abdominal Pain

  A 61-year-old man presented with upper abdominal pain and jaundice. [ncbi.nlm.nih.gov]

  Cholecystitis can cause serious abdominal pain. What are the symptoms of cholecystitis? You should consult a doctor if you have any of the following symptoms: Persistent pain in the upper right abdominal region. [my.clevelandclinic.org]

  You need antibiotics given intravenously (into a vein) to treat infection, and medications to control symptoms of nausea and abdominal pain. [2minutemedicine.com]

• Dyspepsia

  Flatulent dyspepsia: Diagnosis: Ultrasonography is usually the only investigation needed to show gallstones. A bile duct >8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation. [en.wikibooks.org]

  Update: 2012-03-13 Usage Frequency: 4 Quality: Reference: Finnish Akuutti kolekystiitti English Cholecystitis acute Last Update: 2017-04-26 Usage Frequency: 1 Quality: Reference: Wikipedia Finnish Akuutti kolekystiitti English Constipation Diarrhoea Dyspepsia [mymemory.translated.net]

  Biliary colic (colicky RUQ pain ) Especially postprandial May radiate to the epigastrium, right shoulder, and back ( referred pain ) Nausea, vomiting, feelings of satiety Bloating, dyspepsia Choledocholithiasis Colicky RUQ /epigastric pain Nausea, vomiting [amboss.com]

  Other findings, such as fever, nausea, vomiting, diarrhea, dyspepsia, fatigue, altered mental status and jaundice may be present, but they are very nonspecific sysmptoms [ 55, 63 ]. [pancreas.imedpub.com]

• Abdominal Mass

  Jaundice (20%) Murphy sign (pain during inspiration while palpating the right upper quadrant) In calculous cholecystitis, jaundice and an abdominal mass are less common (2). [unboundmedicine.com]

  On physical examination, he presented fatigue, diffuse abdominal pain to superficial and deep palpation, and no abdominal masses or signs of peritoneal irritation. [scielo.br]

  […] aortic aneurysm[14] Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass Clinical (history & physical exam) Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography If patient is unstable: IV fluid resuscitation [en.wikipedia.org]

• Hematochezia

  […] fluid resuscitation Blood transfusion as needed Medications: proton pump inhibitor, octreotide Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) Lower GI Bleed[14] Abdominal pain, hematochezia [en.wikipedia.org]

• Jaundice

  A 61-year-old man presented with upper abdominal pain and jaundice. [ncbi.nlm.nih.gov]

  Courvoisier’s Law: The presence of jaundice, palpable gallbladder means that the jaundice is unlikely to be due to stones. It is tumour of the head of the pancreas until proven otherwise. [armandoh.org]

  Jaundice: Mild jaundice with dark urine and pale stools may also be present. Other symptoms: These include anorexia, nausea, vomiting, sweating and abdominal bloating. [symptoma.com]

  Gallbladder mass which is generally a late finding and it is associated with jaundice found in less than 10 percent of cases. [youtube.com]

• Hepatomegaly

  When examining any patient with suspected gallbladder pathology, it is important to check for signs of inflammation (e.g. tachycardia, pyrexia), signs of peritonitis or perforation, and signs of jaundice or hepatomegaly. [teachmesurgery.com]

  […] fever, adrenal crisis Epigastric Heart: myocardial infarction, pericarditis Stomach: gastritis, stomach ulcer, stomach cancer Pancreas: pancreatitis, pancreatic cancer Intestinal: duodenal ulcer, diverticulitis, appendicitis Right upper quadrant Liver: hepatomegaly [en.wikipedia.org]

  Tender hepatomegaly can be seen in viral hepatitis, congestive heart failure, and alcoholic hepatitis. In choledocholithiasis and cholecystitis, right upper quadrant (RUQ) tenderness is appreciated. [ncbi.nlm.nih.gov]

• Yellow Discoloration of the Skin

  discoloration of the skin and whites of the eyes (jaundice), poor appetite, vomiting, tiredness, abdominal pain, and diarrhea.[1][2] Hepatitis is acute if it resolves within six months, and chronic if it lasts longer than six months.[1][5] Acute hepatitis [en.wikipedia.org]

• Shoulder Pain

  It is the primary complication of cholelithiasis and the most common cause of acute pain in the right upper quadrant (RUQ). Constant right upper quadrant pain that can radiate to the right shoulder. [radiopaedia.org]

  For example, sometimes a patient may not realize that their stomach pain may be related to their recent onset of shoulder pain. [physio-pedia.com]

  Nausea is common and vomiting occurs in 75% of people with cholecystitis.[14] In addition to abdominal pain, right shoulder pain can be present.[13] On physical examination, an inflamed gallbladder is almost always tender to touch and palpable (~25-50% [en.wikipedia.org]

Cholecystitis is diagnosed clinically by history and physical examination. The following signs are specific for cholecystitis.

Murphy’s sign

It is inspiratory arrest during deep palpation of right upper quadrant. It occurs due to touching of the inflammed gallbladder with parietal peritoneum. When parietal peritoneum touches the gallbladder, severe pain is felt and patient immediately withholds the breath by reflex mechanism.

Boas sign

It is hyperesthesia of the skin below the scapula.

Laboratory investigations

• Leukocytosis: Leukocytosis with a left shift may be observed in cholecystitis .
• Ultrasonography: Ultrasonography is the most useful investigation [7]. Acute cholecystitis is indicated by features such as thick walled (>3mm) gallbladder, pericholecystic fluid and sonographic Murphy's sign.
• CT scan: It might not be helpful for detecting gallstones, but usually provides an excellent view of the gallbladder, plus the surrounding structures such as liver, bile duct and pancreas.
• Radionuclide Scan: A hepatobiliary iminodiacetic acid scan will show non filling of gallbladder even after 24 hours of injection. It involves injecting a radioactive chemical in body. The chemical binds to the bile producing-cells, so it can be clearly seen as it travels with the bile through the bile ducts.

The treatment of choice for acute cholecystitis is cholecystectomy; however, patient should be resuscitated and prepared before this operation can be performed. Cholecystectomy can be performed laparoscopically or by open surgery. Laparoscopic cholecystectomy is the better option of the two [8]. Cholecystectomy can be performed within 2-3 days of illness or after 6-10 weeks of initial attack.

More than 90% of uncomplicated cases of acute cholecystitis resolve spontaneously with conservative measures. Conservative measures in this group of patients include the following:

• Nil per oral (i.e. oral intake of food is ceased).
• Antibiotics: Antibiotic regimen in cholecystitis usually consist of broad spectrum antibiotics such as cephalosporins, clindamycin and metronidazole [9] [10].
• Analgesics: Parenteral narcotics can be used to control pain until the inflammation in gall bladder is relieved.
• Intravenous fluids.
• Patient is monitored with blood pressure, pulse and temperature.

Emergency cholecystectomy should be performed in these conditions.

• Worsening of symptoms despite of conservative management.
• Detection of gas in biliary tract.
• Empyema of gallbladder.
• Established generalized peritonitis.
• Gangrene or perforation of gallbladder.

In patients who are severly ill and cannot tolerate general anesthesia, a percutaneous cholecystectomy can be performed under ultrasound guidance.

Patients with chronic cholecystitis require the removal of gallbladder surgically. Moreover, removal of gallstones in common bile duct can be done with newer techniques such as endoscopic retrograde cholangiopancreatography.

Uncomplicated cholecystitis has an excellent prognosis. Most cases of acute cholecystitis recover within a few days to a few weeks. However, 25-30% of patients either require surgery or develop some serious complications such as gangrene, perforation, empyema or rupture of gallbladder. In patients with acalculous cholecystitis, mortality rate can be as high as 50-60%.

The following factors increase the risk of cholecystitis [2] [3].

• Gallstones: As much as 90% of the cases of acute cholecystitis are caused by gallstones obstructing the flow of bile in the biliary tree. Gallstone impaction (called cholelithiasis) mostly occurs at the neck of the gallbladder.
• Female gender: Women have a greater risk of gallstones as compared to men. This makes women more likely to develop cholecystitis.
• Increasing age: The risk of gallstones increases with age.
• Obesity: The incidence of cholecystitis is higher in obese women.
• Drugs: Drugs especially hormonal therapy in women increases the risk of develoing gallstones.
• Bile duct obstruction: This can lead to obstruction of bile flow, thus causing cholecystitis.
• Tumor: A tumor may also prevent bile draining out of gallbladder properly, causing bile buildup that can lead to cholecystitis.

Cholecystectomy performed due to cholecystitis is one of the most common major surgical procedures worldwide. The incidence of cholecystitis increases with age. Gallstones are 2-3 times more common in females than in males. In the United States, the prevalence of gallstones is higher in white people than black people.

In acute calculous cholecystitis, blockage of cystic duct with gallstones causes accumulation of bile in the gallbladder. This can lead to bacterial infection, causing inflammation and distention of the gallbladder. As a result, blood flow and lymphatic drainage are compromised leading to mucosal ischemia, necrosis and cell death.

In acute acalculous cholecystitis, concentrated bile remains stagnant in the lumen causing inflammation of gallbladder and bile duct [4].

Since most of the cases of cholecystitis are caused by gallstones, the risk of cholecystitis can be reduced by controlling the risk factors that lead to the formation of gallstones. These include reduction of weight by regular exercise and avoiding a high fat diet.

Cholecystitis is inflammation of the gallbladder which most commonly occurs due to impaction of gallstones at its neck causing obstruction of the cystic duct. This is known as acute calculous cholecystitis. It results in a buildup of bile in the gallbladder causing it to become inflamed, hyperemic, edematous, tense and distended.

Cholecystitis may also occur in the absence of gallstones in around 10% of the cases [1]. In this case, it is known as acalculous cholecystitis. It critically develops in the patients who are admitted in intensive care units and also in those with extensive burns, sepsis, multiple traumas and hemolytic anemias.
If left untreated, cholecystitis can lead to serious complications, such as gangrene and rupture of gallbladder.

Cholecystitis is the pain and swelling of the gallbladder which occurs most commonly due to stones. The patients usually present with pain in the upper abdomen, fever, vomiting and yellowing of the skin or eyes. The disease is more common in women as compared to men. With proper treatment, the disease has an excellent prognosis.

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