What are the symptoms and treatment options for a patient with cholecystitis?

Symptoms of Cholecystitis

Cholecystitis typically presents with acute, severe right upper quadrant pain that is steady in intensity, often radiates to the upper back, and lasts for hours, accompanied by fever, nausea, and a positive Murphy's sign on examination. 1

Clinical Presentation

Cardinal Symptoms

• Right upper quadrant pain is the hallmark symptom—characteristically acute, intense, and steady rather than colicky 1, 2
• The pain often awakens patients from sleep and has a relatively abrupt onset 2
• Radiation to the upper back or right shoulder is common 2
• Fever is a frequent finding that distinguishes cholecystitis from uncomplicated biliary colic 1
• Nausea and vomiting typically accompany the pain 3, 2

Physical Examination Findings

• Positive Murphy's sign—pain with palpation during deep inspiration—is a classic finding that can be elicited both clinically and on ultrasound examination 1, 4
• Right upper quadrant tenderness on palpation is consistently present 1
• A palpable gallbladder mass may indicate complicated cholecystitis with distension or empyema 1

Laboratory Abnormalities

• Leukocytosis (elevated white blood cell count) is commonly present and supports the diagnosis of acute inflammation 1, 4

Diagnostic Imaging

Ultrasound is the first-line imaging modality of choice due to its high accuracy, low cost, and non-invasive nature 1, 4, 5. Ultrasound has approximately 81% sensitivity and 83% specificity for acute cholecystitis 3.

Key Ultrasound Findings

• Gallstones (present in 90-95% of cases) 3
• Pericholecystic fluid surrounding the gallbladder 1, 4
• Gallbladder wall thickening and edema 1, 4
• Distended gallbladder 4
• Sonographic Murphy's sign—pain when the ultrasound probe presses on the gallbladder 1, 6

Alternative Imaging

• CT with IV contrast is useful when ultrasound is inconclusive or when complications such as perforation or gangrene are suspected 6, 5
• MRCP (magnetic resonance cholangiopancreatography) should be obtained when common bile duct stones are suspected 1, 6
• Hepatobiliary scintigraphy is the gold standard when ultrasound findings are equivocal 3

Treatment Approach

Immediate Management

Early laparoscopic cholecystectomy within 72 hours of diagnosis (and within 7-10 days of symptom onset) is the definitive treatment of choice and results in shorter recovery time, reduced hospitalization, and fewer complications compared to delayed surgery 1, 6, 3.

Medical Management Prior to Surgery

• Initiate antibiotic therapy immediately with Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours for immunocompetent, non-critically ill patients 1, 6
• For documented beta-lactam allergy, use Eravacycline 1 mg/kg IV every 12 hours or Tigecycline 100 mg loading dose then 50 mg IV every 12 hours 1, 6
• For critically ill or immunocompromised patients, use Piperacillin/Tazobactam 4g/0.5g IV every 6 hours 1
• Provide IV fluid resuscitation and analgesia as needed 7

Surgical Timing

• Optimal timing is within 72 hours of diagnosis, with acceptable extension up to 7-10 days from symptom onset 6, 7, 3
• Single-dose antibiotic prophylaxis is sufficient if early intervention occurs 1, 6
• No postoperative antibiotics are necessary for uncomplicated cholecystitis with adequate source control 4, 1, 6

Alternative Management for High-Risk Patients

• If early surgery cannot be performed within the optimal timeframe, delay cholecystectomy to at least 6 weeks after presentation 6, 7
• Percutaneous cholecystostomy (drainage catheter placement) may be considered for patients with multiple comorbidities who are unfit for surgery, though this is associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 6, 3

Important Clinical Pitfalls

• Do not confuse dyspeptic symptoms (bloating, belching, food intolerance) with true biliary pain—these symptoms are common in patients with gallstones but are often unrelated and frequently persist after surgery 2
• Do not delay surgery beyond 10 days from symptom onset, as this increases complication rates and recurrence risk 6
• Do not provide prolonged antibiotic courses (>7 days) without investigating for complications or inadequate source control 1, 6
• In pregnant patients, early laparoscopic cholecystectomy during any trimester is associated with lower maternal-fetal complications (1.6%) compared to delayed management (18.4%) 3
• In elderly patients (>65 years), laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 3