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

  — Felissa Allard, SELF, "These Are The Pregnancy Pains You Shouldn’t Ignore," 8 July 2019 If the gallstones cause infection in the gallbladder (cholecystitis) or block the flow of bile from the liver to the intestines through the bile duct,fever and chills [merriam-webster.com]

  You have a fever or chills. You have pain when you urinate. Your skin or eyes turn yellow. You have questions or concerns about your condition or care. Care Agreement You have the right to help plan your care. [drugs.com]

  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]

• Lymphadenopathy

  […] gallbladder distension An inflammatory reaction occurs due to either mucosal ischemia from increased hydrostatic pressure or cytotoxic effects of bile degradation Causes Gallstones (95% of patients with cholecystitis) Fibrosis Parasitic infection Tumor Lymphadenopathy [coreem.net]

  […] insufficiency, kidney calculus, deep vein thrombosis, pulmonary embolism, membranous glomerulonephropathy, polymyositis, thrombophlebitis, liver damage, leucopenia, paresis, paresthesia, vertigo, allergic alveolitis, angioedema, scleritis, bone fracture, lymphadenopathy [mymemory.translated.net]

  No lymphadenopathy was detected. FDG-PET/CT scan showed increased activity in the thickened wall of the gallbladder. The increased uptake area appeared to extend into the liver parenchyma (Figure 2C and D ). [doi.org]

  Findings of diffuse lymphadenopathy especially Virchow’s nodes can be suggestive of underlying malignancy. [ncbi.nlm.nih.gov]

• Constitutional Symptom

  Constitutional symptoms. Myocardial infarction/acute coronary syndrome: electrocardiogram (EKG) changes. Positive troponins. Associated symptoms such as dyspnea. Associated with exertion. History of coronary artery disease. [cancertherapyadvisor.com]

  [edit] Hepatitis has a broad spectrum of presentations that range from a complete lack of symptoms to severe liver failure.[15][16][17] The acute form of hepatitis, generally caused by viral infection, is characterized by constitutional symptoms that [en.wikipedia.org]

• Nausea

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

  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]

  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]

  This is usuallyaccompanied by diarrhea,vomiting and nausea. Thegallbladder may be tenderand distended. 9. [slideshare.net]

  […] duct (CBD) or common hepatic duct compression) Acute Hepatitis Hepatic abscess Right lower lobe pneumonia Cholangitis Pancreatitis Pyelonephritis Presentation History Right upper quadrant (RUQ) pain History of similar, self-limited pain (biliary colic) Nausea [coreem.net]

• Abdominal Pain

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

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

  In the context of acute biliary pancreatitis may merge acute abdominal diseases different to each other; but they have in common hyperamylasemia and acute/severe upper abdominal pain and abdominal wall guarding. [intechopen.com]

• Right Upper Quadrant Pain

  All patients with acute right upper quadrant pain should be evaluated for sonographic signs of acute cholecystitis. Sonography of the gallbladder is best performed with a 5-MHz curved array transducer. [ultrasoundtraining.com]

  Acute cholecystitis refers to inflammation of the gallbladder and classically presents as a syndrome of right upper quadrant pain, fever, and leucocytosis. [aci.health.nsw.gov.au]

  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]

  Herein, we described a morbidly obese patient with poorly controlled diabetes presenting with non-specific right upper quadrant pain and was subsequently diagnosed with haemorrhagic cholecystitis. [ncbi.nlm.nih.gov]

• Upper Abdominal Pain

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

  RUQ and epigastric radiation to left upper back persists beyond 6 hours often between 2100-0400 N+V Signs dull, poorly localised -> sharp, well localised mid-upper abdominal pain Risk factors increased age female parity obesity diabetes mellitus profound [lifeinthefastlane.com]

  Biliary colic is characterized by the sudden onset of intense right upper abdominal pain that may radiate to the shoulder. Sweating and vomiting are common. The pain tends to be steady and lasts up to three hours. [aafp.org]

  […] lang=us\u0026email="} The 5-F rule refers to risk factors for the development of cholelithiasis in the event of upper abdominal pain: fair: more prevalent in the Caucasian population 1 fat: BMI >30 female fertile: one or more children forty: age ≥40 cholelithiasis [radiopaedia.org]

• Acute Abdomen

  We report the case of an 80-year-old woman presenting with an acute abdomen and clinical peritonitis. Her serum amylase was raised to 878 iu/l. [ncbi.nlm.nih.gov]

  Acute cholecystitis Acute cholecystitis is the fourth most common cause of hospital admissions for patients presenting with an acute abdomen [4], and it is the prime diagnostic concern when a thick-walled gallbladder is found at imaging. [radiologyassistant.nl]

  Acute Cholecystitis Acute cholecystitis is the fourth most common cause of hospital admissions for patients presenting with an acute abdomen [ 4 ], and it is the prime diagnostic concern when a thick-walled gallbladder is found at imaging. [doi.org]

  Laboratory tests References: [8] [1] [9] Differential diagnoses Differential diagnosis of an acute abdomen Differential diagnosis of RUQ pain Abdominal Acute cholangitis Acute hepatic capsule swelling (e.g., acute hepatitis, perihepatitis, congestive [amboss.com]

  It is very important to define accurately the reliable data that the US can provide in different diseases that can cause an acute abdomen. [intechopen.com]

• Heart Disease

  The American Journal of the Medical Sciences, 213, 598-602. http://dx.doi.org/10.1097/00000441-194705000-00011 [ 13 ] Gilbert, N.C. (1942) Influence of Extrinsic Factors on the Coronary Flow and Clinical Course of Heart Disease. [dx.doi.org]

  Some chronic medical conditions, like kidney failure, coronary heart disease, or certain types of cancer also increase the risk of cholecystitis. [medicalnewstoday.com]

• Thrombosis

  […] gangrenous cholecystitis (most common - 20%) 8 gallbladder perforation (~5%) 8,9 emphysematous cholecystitis pericholecystic abscess cholecystoenteric fistula cholecystocutaneous fistula 10 vascular complications ( gallbladder hemorrhage, portal vein thrombosis [radiopaedia.org]

  However, E.C mostly results from thrombosis or occlusion of the cystic artery with ischemic necrosis of the gallbladder wall. [casesjournal.biomedcentral.com]

  […] myocardial ischaemia, chest pain, syncope, cerebral ischaemia, hypertension, hypotension, cholecystitis, pancreatitis, gastrointestinal haemorrhage, bursitis, confusion, depression, dyspnoea, abnormal healing, renal insufficiency, kidney calculus, deep vein thrombosis [mymemory.translated.net]

  Signs/symptoms of deep vein thrombosis. Acute pancreatitis: Can co-exist with cholecystitis. Elevated lipase and/or amylase. Pleurisy/pneumonia: Pleuritic pain (though cholecystitis pain can be pleuritic). Dyspnea. Cough. Liver Abscess: High fevers. [cancertherapyadvisor.com]

• Vascular Disease

  In severe liver disease, HIDA scan can be falsely positive if biliary excretion is not normal. C. Systolic and Diastolic Heart Failure. No change in standard management. D. Coronary Artery Disease or Peripheral Vascular Disease. [cancertherapyadvisor.com]

  disease, peripheral neuropathy, RA, orther inflammatory diseases. [richtlijnendatabase.nl]

  "Chapter 83 Vascular Diseases of the Liver" (Online). Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Saunders. ISBN 978-1416061892. Archived from the original on 4 March 2016. [en.wikipedia.org]

• Jaundice

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

  Because bilirubin contains a yellowish color, it causes a yellowish cast to the skin and eyes that is called jaundice. Gallstone formation is seen in twice as many women as men, particularly those between the ages of 20 and 60. [medical-dictionary.thefreedictionary.com]

  The classicalsign of cholangitis is Charcots triad, which is rightupper quadrant pain, fever and jaundice. [slideshare.net]

  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]

• 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]

  The pain may be crampy and episodic, or it may be constant. The pain is often described as pushing through to the right upper back and shoulder. Because deep breathing increases the pain, breathing becomes shallow. [medical-dictionary.thefreedictionary.com]

• Withdrawn

  […] first-line triple-regimen therapy failed.[14] After H. pylori is eradicated, there is low risk of recurrent ulcer bleeding when NSAIDs are resumed.[14] NSAIDs induced ulcers[edit] NSAID-associated ulcers heal in 6 to 8 weeks provided the NSAIDs are withdrawn [en.wikipedia.org]

• Dark Urine

  It can also be accompanied by: jaundice pale stools dark urine abdominal pain nausea See your doctor if you have itching in pregnancy. [healthline.com]

  Jaundice, dark urine, light-colored stools, and generalized itchiness are characteristic symptoms of cholestasis. Jaundice results from excess bilirubin deposited in the skin, and dark urine results from excess bilirubin excreted by the kidneys. [merckmanuals.com]

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.

1. Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. Jan 2010;8(1):15-22.
2. Soustek Z, Dyrhonova V. [Etiology and therapy of cholecystitis and cholelithiasis]. Zeitschrift fur die gesamte innere Medizin und ihre Grenzgebiete. Nov 1 1981;36(21):824-829.
3. Velikoretskii AN. [Cholelithiasis and cholecystitis (etiology, pathogenesis and classification)]. Fel'dsher i akusherka. Apr 1979;44(4):16-19.
4. Donovan JM. Physical and metabolic factors in gallstone pathogenesis. Gastroenterology clinics of North America. Mar 1999;28(1):75-97.
5. Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Annals of emergency medicine. Sep 1996;28(3):273-277.
6. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emergency medicine clinics of North America. Nov 1996;14(4):719-737.
7. Roe J. Evidence-based emergency medicine. Clinical assessment of acute cholecystitis in adults. Annals of emergency medicine. Jul 2006;48(1):101-103.
8. Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RT, Toouli J. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Annals of surgery. Nov 1993;218(5):630-634.
9. Kittisupamongkol W. Role of antibiotics in the severity of cholecystitis. American journal of surgery. May 2010;199(5):723; author reply 722-723.
10. Lishchenko AN. [Is it necessary to use antibiotics in acute cholecystitis?]. Khirurgiia. Jul 1986(7):51-53.