Clinical Topic A-Z Clinical Speciality

Cholecystitis - acute

Cholecystitis - acute
D041881Cholecystitis, Acute
Gastrointestinal
2012-09-01Last revised in September 2012

Cholecystitis - acute - Summary

Acute cholecystitis is inflammation of the gallbladder, the most common cause of which is gallstones.

It is estimated that 95% of people with acute cholecystitis have gallstones or biliary sludge that have become impacted at the neck of the gallbladder.

Approximately 5% of people who present with acute cholecystitis do not have gallstones. These are usually people who have been hospitalized for trauma or acute biliary illness.

The following are risk factors for gallstone formation:

Female gender.

Increasing age.

Obesity.

Rapid weight loss.

Pregnancy.

Crohn's disease.

Hyperlipidaemia.

Diabetes mellitus.

Genetics (e.g. maternal family history of gallstones).

If acute cholecystitis is untreated the following complications may occur:

Perforation of the gallbladder.

Biliary peritonitis.

Peri-cholecystic abscess.

Fistula (between the gallbladder and duodenum).

Mortality from acute cholecystitis is estimated to be less than 10%. The mortality of elderly people (over 75 years of age) tends to be higher than that of younger people, and comorbidity such as diabetes may increase the risk of death.

Acute cholecystitis should be suspected when someone presents with:

A history of sudden-onset, constant, severe pain in the upper right quadrant, and possibly anorexia, nausea, vomiting, and sweating.

Low grade fever (a high temperature is uncommon).

Tenderness in the upper right quadrant, with or without Murphy's sign (inspiration is inhibited by pain on palpitation) on examination.

A history of gallstones (cholelithiasis) is often present. Cholecystitis without biliary colic usually has a gradual onset.

Other diagnoses should be excluded, such as peptic ulcer disease, liver disease, pancreatitis, and cardiac disease.

An abdominal ultrasound and blood tests (e.g. raised leukocyte count and C-reactive protein) will help to confirm the diagnosis; however they are not usually performed in primary care because of the need for urgent referral to secondary care.

Signs which may indicate a complication include:

Right upper quadrant palpable mass (distended gallbladder or an inflammatory mass around the inflamed gallbladder).

Fever (evidence of sepsis).

Jaundice (stone in the bile duct or external compression of the biliary ducts, for example Mirrizzi syndrome).

Urgent admission to hospital is recommended for anyone with suspected acute cholecystitis for:

Confirmation of the diagnosis (e.g. abdominal ultrasound, and blood tests such as a raised white blood cell count, and C-reactive protein, and serum amylase).

Monitoring (e.g. blood pressure, pulse, and urinary output).

Treatment (e.g. intravenous fluids, antibiotics, and analgesia).

Surgical assessment for cholecystectomy.

Routine referral of people with mild intermittent symptoms and who are not unwell should be considered.

An oral nonsteroidal anti-inflammatory drug (e.g. diclofenac) or, if the pain is severe, intramuscular pethidine may be considered while the person is waiting to be admitted.

Have I got the right topic?

216months3060monthsBoth

This CKS topic is based on International Consensus Guidelines on Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis published in 2007 [Kimura et al, 2007].

This CKS topic covers the diagnosis and management of acute cholecystitis in adults presenting in primary care.

This CKS topic does not cover the management of cholangitis or other causes of right upper quadrant pain.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in September 2012

July 2013 — minor update. Diclofenac has been replaced as a treatment option with naproxen, following recent MHRA guidelines [MHRA, 2013].

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

Previous changes

July to September 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2012.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2012.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 September 2012.

Primary evidence

No new randomized controlled trials published in the major journals since 1 September 2012.

New policies

No new national policies or guidelines since 1 September 2012.

New safety alerts

No new safety alerts since 1 September 2012.

Changes in product availability

No changes in product availability since 1 September 2012.

Goals and outcome measures

Goals

Making an accurate diagnosis

Appropriate referral to secondary care or other specialist service

Background information

Definition

What is it?

Acute cholecystitis is inflammation of the gallbladder [Indar and Beckingham, 2002].

Causes

What causes it?

The most common cause of acute cholecystitis is gallstones.

It is estimated that 95% of people with acute cholecystitis have gallstones or biliary sludge that have become impacted at the neck of the gallbladder [Ahmad et al, 2000].

Approximately 5% of people who present with acute cholecystitis do not have gallstones. These are usually people who have been hospitalized for trauma or acute biliary illness [Indar and Beckingham, 2002; Kimura et al, 2007].

Risk factors

What are the risk factors?

The following are risk factors for gallstone formation [Ahmad et al, 2000]:

Female gender.

Increasing age.

Obesity.

Rapid weight loss.

Pregnancy.

Crohn's disease.

Hyperlipidaemia.

Diabetes mellitus.

Genetics (e.g. maternal family history of gallstones).

Complications

What are the complications?

If acute cholecystitis is untreated the following complications may occur [Kimura et al, 2007]:

Perforation of the gallbladder.

Biliary peritonitis.

Peri-cholecystic abscess.

Fistula (between the gallbladder and duodenum).

Mortality from acute cholecystitis is estimated to be less than 10%. The mortality of elderly people (over 75 years of age) tends to be higher than that of younger people, and comorbidity such as diabetes may increase the risk of death [Kimura et al, 2007].

Diagnosis

Diagnosis of acute cholecystitis

Diagnosis

What features suggest a diagnosis acute cholecystitis?

Suspect acute cholecystitis when someone presents with:

A history of sudden-onset, constant, severe pain in the upper right quadrant, and possibly anorexia, nausea, vomiting, and sweating.

Low grade fever (a high temperature is uncommon).

Tenderness in the upper right quadrant, with or without Murphy's sign (inspiration is inhibited by pain on palpitation) on examination. A positive Murphy's sign has specificity of 79-96% for acute cholecystitis [Miura et al, 2007]

History of gallstones (cholelithiasis) is often present. Cholecystitis without biliary colic usually has a gradual onset.

Exclude other diagnoses such as peptic ulcer disease, liver disease, pancreatitis, and cardiac disease.

See the CKS topics on CVD risk assessment and management and Dyspepsia - unidentified cause for more information.

Look for signs which may indicate a complication:

Right upper quadrant palpable mass (distended gallbladder or an inflammatory mass around the inflamed gallbladder).

Fever (evidence of sepsis).

Jaundice (stone in the bile duct or external compression of the biliary ducts, for example Mirrizzi syndrome).

Additional information

Additional information

An abdominal ultrasound and blood tests (primarily. raised leukocyte count and C-reactive protein) will help to confirm the diagnosis of acute cholecystitis, however there is no specific test. Tests of this nature are not usually performed in primary care because of the need for urgent referral to secondary care [Miura et al, 2007].

Diagnostic imaging is utilised in secondary care to determine the presence and cause of biliary obstruction; characteristic indicators of acute cholecystitis include an enlarged gallbladder, thickening of the gallbladder wall, gall stones and sonographic Murphy's sign (has specificity >90% for acute cholecystsitis) [Miura et al, 2007]

Basis for recommendation

Basis for recommendation

These recommendations are based on a published clinical review of acute cholecystitis [Indar and Beckingham, 2002], a review of differential diagnosis of gallstone-induced complications [Ahmad et al, 2000], and guidelines from an international consensus meeting [Miura et al, 2007].

Management

Management

Scenario: Management : covers the management of people with acute cholecystitis.

Scenario: Management

Scenario: Management of acute cholecystitis

216months3060monthsBoth

Management

How do I manage someone with acute cholecystitis?

Urgently admit to hospital anyone with suspected acute cholecystitis for:

Confirmation of the diagnosis (e.g. abdominal ultrasound, and blood tests such as a raised white blood cell count, and C-reactive protein, and serum amylase).

Monitoring (e.g. blood pressure, pulse, and urinary output).

Treatment (e.g. intravenous fluids, antibiotics, and analgesia).

Surgical assessment for cholecystectomy.

Consider routine referral of people with mild intermittent symptoms and who are not unwell.

Consider prescribing an oral nonsteroidal anti-inflammatory drug (e.g. naproxen) or, if the pain is severe, consider giving intramuscular pethidine while the person is waiting to be admitted.

Basis for recommendation

Basis for recommendation

These recommendations are based on a published clinical review of acute cholecystitis [Indar and Beckingham, 2002] and guidelines from an international consensus meeting [Miura et al, 2007].

Urgent referral to secondary care is recommended because of the high mortality rate (up to 10%) associated with acute cholecystitis.

Evidence

Evidence

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of acute cholecystitis.

Search dates

June 2008 - September 2012

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Cholecystitis, Acute/, (acute ADJ cholecystitis).tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

Ahmad, M., Cheung, R.C., Keeffe, E.B. and Ahmed, A. (2000) Differential diagnosis of gallstone-induced complications. Southern Medical Journal 93(3), 261-264. [Abstract]

Indar, A.A. and Beckingham, I.J. (2002) Acute cholecystitis. BMJ 325(7365), 639-643. [Free Full-text]

Kimura, Y., Takada, T., Kawarada, Y. et al. (2007) Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo guidelines. Journal of Hepato-biliary-pancreatic Surgery 14(1), 15-26. [Abstract] [Free Full-text]

MHRA (2013) Diclofenac: new contraindications and warnings after a Europe-wide review of cardiovascular safety. Drug Safety Update 6(11), A2. [Free Full-text]

Miura, F., Takada, T., Kawarada, Y. et al. (2007) Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo guidelines. Journal of Hepato-biliary-pancreatic Surgery 14(1), 27-34. [Abstract] [Free Full-text]