View source for Cholecystitis

{{Short description|Inflammation of the gallbladder}}
{{Infobox medical condition (new)
| name            = Cholecystitis
| synonyms        =
| image           = AcuteCholMark.png
| alt             =
| caption         = Acute cholecystitis as seen on CT. Note the fat stranding around the enlarged gallbladder.
| pronounce       =
| field           = [[General surgery]], [[gastroenterology]]
| symptoms        = Intense right upper [[abdominal pain]], nausea, [[vomiting]], [[fever]]<ref name=NEJM2008/>
| onset           =
| duration        = Short term or long term<ref name=Sle2010/>
| causes          = Gallstones, severe illness<ref name=NEJM2008/><ref>{{cite book|last1=Levy|first1=Angela D.|last2=Mortele|first2=Koenraad J.|last3=Yeh|first3=Benjamin M.|title=Gastrointestinal Imaging|date=2015|publisher=Oxford University Press|isbn=978-0-19-939214-8|page=456|url=https://books.google.com/books?id=EJhJCAAAQBAJ&pg=PA456|language=en|url-status=live|archive-url=https://web.archive.org/web/20170908192055/https://books.google.com/books?id=EJhJCAAAQBAJ&pg=PA456|archive-date=2017-09-08}}</ref>
| risks           = [[Combined oral contraceptive pill|Birth control pills]], [[pregnancy]], family history, [[obesity]], [[diabetes]], [[cirrhosis|liver disease]], rapid [[weight loss]]<ref name=NIH2013/>
| diagnosis       = Abdominal [[Ultrasound imaging|ultrasound]]<ref name=WS2016/>
| differential    = [[Hepatitis]], [[peptic ulcer disease]], [[pancreatitis]], [[pneumonia]], [[angina]]<ref>{{cite book|last1=Ferri|first1=Fred F.|title=Ferri's differential diagnosis: a practical guide to the differential diagnosis of symptoms, signs, and clinical disorders|date=2010|publisher=Elsevier/Mosby|location=Philadelphia, PA|isbn=978-0-323-07699-9|page=Chapter C|edition=2nd}}</ref>
| prevention      =
| treatment       = [[cholecystectomy|Gallbladder removal surgery]], [[gallbladder drainage]]<ref name=Pat2015/><ref name=WS2016/>
| medication      =
| prognosis       = Generally good with treatment<ref name=NIH2013/>
| frequency       =
| deaths          =
}}
<!-- Definition and symptoms -->
'''Cholecystitis''' is [[inflammation]] of the [[gallbladder]].<ref name=NICE2014>{{cite report|last1=Internal Clinical Guidelines Team|title=Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Clinical Guideline 188|date=October 2014|pmid=25473723|page=101}}</ref> Symptoms include [[Right upper quadrant (abdomen)|right upper]] [[abdominal pain]], pain in the right shoulder, nausea, vomiting, and occasionally fever.<ref name=NEJM2008/> Often [[gallbladder attacks]] (biliary colic) precede acute cholecystitis.<ref name=NEJM2008/> The pain lasts longer in cholecystitis than in a typical gallbladder attack.<ref name=NEJM2008/> Without appropriate treatment, recurrent episodes of cholecystitis are common.<ref name="NEJM2008" /> Complications of acute cholecystitis include [[gallstone pancreatitis]], [[common bile duct stones]], or [[cholangitis|inflammation of the common bile duct]].<ref name=NEJM2008>{{cite journal|last1=Strasberg|first1=SM|title=Clinical practice. Acute calculous cholecystitis.|journal=The New England Journal of Medicine|date=26 June 2008|volume=358|issue=26|pages=2804–11|pmid=18579815|doi=10.1056/nejmcp0800929}}</ref><ref name=NICE2014/>

<!-- Cause and diagnosis -->
More than 90% of the time acute cholecystitis is caused from blockage of the [[cystic duct]] by a [[gallstone]].<ref name=NEJM2008/> Risk factors for gallstones include [[combined oral contraceptive pill|birth control pills]], [[pregnancy]], a family history of gallstones, [[obesity]], [[diabetes]], [[cirrhosis|liver disease]], or rapid [[weight loss]].<ref name=NIH2013>{{cite web|title=Gallstones|url=https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/gallstones/Pages/facts.aspx|website=NIDDK|access-date=27 July 2016|date=November 2013|archive-url=https://web.archive.org/web/20160728005016/https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/gallstones/Pages/facts.aspx|archive-date=28 July 2016}}</ref> Occasionally, acute cholecystitis occurs as a result of [[vasculitis]] or [[chemotherapy]], or during recovery from [[major trauma]] or [[burn]]s.<ref name=Acal2015>{{cite book|title=Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management|date=2015|publisher=Elsevier Health Sciences|isbn=978-1-4557-4989-8|page=1154|edition=10|chapter-url=https://books.google.com/books?id=4CMJBgAAQBAJ&pg=RA1-PA21|chapter=Section VIII|url-status=live|archive-url=https://web.archive.org/web/20170908192055/https://books.google.com/books?id=4CMJBgAAQBAJ&pg=RA1-PA21|archive-date=2017-09-08}}</ref> Cholecystitis is suspected based on symptoms and laboratory testing.<ref name=WS2016/> Abdominal [[Ultrasound imaging|ultrasound]] is then typically used to confirm the diagnosis.<ref name=WS2016/>

<!-- Prevention and treatment -->
Treatment is usually with [[laparoscopic cholecystectomy|laparoscopic gallbladder removal]], within 24 hours if possible.<ref name=Pat2015/><ref>{{cite journal|last1=Schuld|first1=J|last2=Glanemann|first2=M|title=Acute Cholecystitis.|journal=Viszeralmedizin|date=June 2015|volume=31|issue=3|pages=163–5|pmid=26468309|doi=10.1159/000431275|pmc=4569253}}</ref> Taking pictures of the bile ducts during the surgery is recommended.<ref name=Pat2015>{{cite journal|last1=Patel|first1=PP|last2=Daly|first2=SC|last3=Velasco|first3=JM|title=Training vs practice: A tale of opposition in acute cholecystitis.|journal=World Journal of Hepatology|date=18 October 2015|volume=7|issue=23|pages=2470–3|pmid=26483868|doi=10.4254/wjh.v7.i23.2470|pmc=4606202 |doi-access=free }}</ref> The routine use of [[antibiotics]] is controversial.<ref name=WS2016/><ref name=Van2016>{{cite journal|last1=van Dijk|first1=AH|last2=de Reuver|first2=PR|last3=Tasma|first3=TN|last4=van Dieren|first4=S|last5=Hugh|first5=TJ|last6=Boermeester|first6=MA|title=Systematic review of antibiotic treatment for acute calculous cholecystitis.|journal=The British Journal of Surgery|date=June 2016|volume=103|issue=7|pages=797–811|pmid=27027851|doi=10.1002/bjs.10146|s2cid=205507793}}</ref> They are recommended if surgery cannot occur in a timely manner or if the case is complicated.<ref name=WS2016/> [[Choledocholithiasis|Stones in the common bile duct]] can be removed before surgery by [[endoscopic retrograde cholangiopancreatography]] (ERCP) or during surgery.<ref name=Pat2015/> Complications from surgery are rare.<ref name=NIH2013/> In people unable to have surgery, [[gallbladder drainage]] may be tried.<ref name=WS2016/>

<!-- History, epidemiology, and culture -->
About 10–15% of adults in the developed world have gallstones.<ref name=WS2016/> Women more commonly have stones than men and they occur more commonly after age 40.<ref name=NIH2013/> Certain [[ethnic group]]s are more often affected; for example, 48% of [[Native Americans in the United States|American Indian]]s have gallstones.<ref name=NIH2013/> Of all people with stones, 1–4% have biliary colic each year.<ref name=WS2016/> If untreated, about 20% of people with biliary colic develop acute cholecystitis.<ref name=WS2016>{{cite journal|last1=Ansaloni|first1=L|title=2016 WSES guidelines on acute calculous cholecystitis.|journal=World Journal of Emergency Surgery |date=2016|volume=11|page=25|pmid=27307785|doi=10.1186/s13017-016-0082-5|pmc=4908702|doi-access=free}}</ref> Once the gallbladder is removed outcomes are generally good.<ref name=NIH2013/> Without treatment, chronic cholecystitis may occur.<ref name=Sle2010>{{cite book|url=https://books.google.com/books?id=zEZOqB6r9hwC&pg=PA1065|title=Sleisenger & Fordtran's Gastrointestinal and liver disease pathophysiology, diagnosis, management|date=2010|publisher=MD Consult|isbn=978-1-4377-2767-8|edition=9|location=[S.l.]|page=1065|last1=Feldman|first1=Mark|url-status=live|archive-url=https://web.archive.org/web/20170908192055/https://books.google.com/books?id=zEZOqB6r9hwC&pg=PA1065|archive-date=2017-09-08}}</ref> The word is from [[Greek language|Greek]], ''cholecyst-'' meaning "gallbladder" and ''-itis'' meaning "inflammation".<ref>{{cite book|last1=Collins|first1=Edwards|title=A Short Course in Medical Terminology|date=2013|publisher=Lippincott Williams & Wilkins|isbn=978-1-4698-3578-5|page=246|url=https://books.google.com/books?id=5mWaAgAAQBAJ&pg=PA246|url-status=live|archive-url=https://web.archive.org/web/20170908192055/https://books.google.com/books?id=5mWaAgAAQBAJ&pg=PA246|archive-date=2017-09-08}}</ref>
{{TOC limit|3}}

==Signs and symptoms==
[[File:Blausen 0428 Gallbladder-Liver-Pancreas Location.png|thumb|Location of the gallbladder]]
Most people with gallstones do not have symptoms.<ref name=NEJM2008/> However, when a gallstone temporarily lodges in the cystic duct, they experience [[biliary colic]].<ref name=NEJM2008/>  Biliary colic is [[abdominal pain]] in the [[right upper quadrant]] or [[epigastric region]]. It is episodic, occurring after eating greasy or fatty foods, and leads to nausea and/or vomiting.<ref name=":1">Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine, 18e</ref> People with cholecystitis most commonly have symptoms of biliary colic before developing cholecystitis. The pain becomes severe and constant in cholecystitis. Nausea is common and vomiting occurs in 75% of people with cholecystitis.<ref name=":2">Friedman L.S. (2015). Liver, Biliary Tract, & Pancreas Disorders. In Papadakis M.A., McPhee S.J., Rabow M.W. (Eds), Current Medical Diagnosis & Treatment 2015</ref> In addition to abdominal pain, right shoulder pain can be present.<ref name=":1" />

On physical examination, an inflamed gallbladder is almost always tender to the touch and palpable (~25-50% of cases) in the midclavicular right lower rib margin.<ref name=":1" /> Additionally, a fever is common.<ref name=":2" /> Pain with deep inspiration leading to termination of the breath while pressing on the right upper quadrant of the abdomen usually causes severe pain ([[Murphy's sign]]).<ref>{{cite journal|last1=Singer|first1=AJ|last2=McCracken|first2=G|last3=Henry|first3=MC|last4=Thode HC|first4=Jr|last5=Cabahug|first5=CJ|title=Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis.|journal=Annals of Emergency Medicine|date=September 1996|volume=28|issue=3|pages=267–72|pmid=8780468|doi=10.1016/s0196-0644(96)70024-0}}</ref> [[Jaundice|Yellowing of the skin]] (jaundice) may occur but is often mild. Severe jaundice suggests another cause of symptoms such as [[choledocholithiasis]].<ref name=":2" /> People who are old, have [[diabetes]], chronic illness, or who are immunocompromised may have vague symptoms that may not include fever or localized tenderness.<ref name=":4">{{cite journal|last1=Demehri|first1=FR|last2=Alam|first2=HB|title=Evidence-Based Management of Common Gallstone-Related Emergencies|journal=Journal of Intensive Care Medicine|volume=31|issue=1|pages=3–13|date=15 October 2014|pmid=25320159|doi=10.1177/0885066614554192|s2cid=8792764}}</ref>

===Complications===
A number of complications may occur from cholecystitis if not detected early or properly treated. Signs of complications include high fever, [[Shock (circulatory)|shock]] and [[jaundice]]. Complications include the following:<ref name=":1" />
* [[Gangrene]]
* Gallbladder [[perforation|rupture]]
* [[Empyema]]
* [[Fistula]] formation and [[gallstone ileus]]
* [[Rokitansky-Aschoff sinuses]]

==== Gangrene and gallbladder rupture ====
Cholecystitis causes the gallbladder to become distended and firm.  Distension can lead to decreased blood flow to the gallbladder, causing [[necrosis|tissue death]] and eventually gangrene.<ref name=":1" />  Once tissue has died, the gallbladder is at greatly increased risk of rupture (perforation), which can cause sharp pain. Rupture can also occur in cases of chronic cholecystitis.<ref name=":1" /> Rupture is a rare but serious complication that leads to [[abscess]] formation or [[peritonitis]].<ref name=":2" />  Massive rupture of the gallbladder has a mortality rate of 30%.<ref name=":1" />

==== Empyema ====
Untreated cholecystitis can lead to worsened inflammation and infected [[bile]] that can lead to a collection of [[pus]] inside the gallbladder, also known as [[empyema]].<ref name=":1" /> The symptoms of empyema are similar to uncomplicated cholecystitis but greater severity: high fever, severe abdominal pain, more severely elevated white blood count.<ref name=":1" />

==== Fistula formation and gallstone ileus ====
The inflammation of cholecystitis can lead to [[Adhesion (medicine)|adhesions]] between the gallbladder and other parts of the [[Human gastrointestinal tract|gastrointestinal tract]], most commonly the [[duodenum]].<ref name=":1" /> These adhesions can lead to the formation of direct connections between the gallbladder and gastrointestinal tract, called [[fistula]]s.<ref name=":1" /> With these direct connections, gallstones can pass from the gallbladder to the intestines.  Gallstones can get trapped in the gastrointestinal tract, most commonly at the connection between the small and large intestines ([[ileocecal valve]]).  When a gallstone gets trapped, it can lead to an [[intestinal obstruction]], called [[gallstone ileus]], leading to abdominal pain, vomiting, [[constipation]], and [[abdominal distension]].<ref name=":1" />

==Causes==
Cholecystitis occurs when the gallbladder becomes inflamed.<ref name=":1" /> Gallstones are the most common cause of gallbladder inflammation but it can also occur due to blockage from a tumor or scarring of the bile duct.<ref name=":1" /><ref name=":3">{{Cite web|url = http://www.mayoclinic.org/diseases-conditions/cholecystitis/basics/causes/con-20034277|title = Cholecystitis|date = 28 August 2014|access-date = 13 November 2014|website = Mayo Clinic|url-status = live|archive-url = https://web.archive.org/web/20141125191936/http://www.mayoclinic.org/diseases-conditions/cholecystitis/basics/causes/con-20034277|archive-date = 25 November 2014}}</ref> The greatest risk factor for cholecystitis is gallstones.<ref name=":3" />  Risk factors for gallstones include female sex, increasing age, pregnancy, oral contraceptives, obesity, diabetes mellitus, ethnicity (Native North American), rapid weight loss.<ref name=":1" />

=== Acute calculous cholecystitis ===
Gallstones blocking the flow of bile account for 90% of cases of cholecystitis (acute calculous cholecystitis).<ref name=NEJM2008/><ref name=":2" />  Blockage of bile flow leads to [[inspissation|thickening]] and buildup of [[bile]] causing an enlarged, red, and tense gallbladder.<ref name=NEJM2008/> The gallbladder is initially [[Asepsis|sterile]] but often becomes infected by bacteria, predominantly ''[[E. coli]]'', ''[[Klebsiella]]'', ''[[Streptococcus]]'', and ''[[Clostridium]]'' species.<ref name=":1" />  Inflammation can spread to the outer covering of the gallbladder and surrounding structures such as the diaphragm, causing [[Referred pain|referred right shoulder pain]].<ref name=":1" />

=== Acalculous cholecystitis ===
In acalculous cholecystitis, no stone is in the biliary ducts.<ref name=":1" /> It accounts for 5–10% of all cases of cholecystitis and is associated with high morbidity and mortality rates.<ref name=":1" /> Acalculous cholecystitis is typically seen in people who are hospitalized and critically ill.<ref name=":1" /> Males are more likely to develop acute cholecystitis following surgery in the absence of trauma.<ref name=":2" /><ref>Barie PS. Acalculous and postoperative cholecystitis. In: Surgical intensive care, Barie PS, Shires GT. (Eds), Little Brown & Co, Boston 1993. p.837.</ref> It is associated with many causes including [[vasculitis]], [[chemotherapy]], [[major trauma]] or [[burn]]s.<ref name="Acal2015"/>

The presentation of acalculous cholecystitis is similar to calculous cholecystitis.<ref>{{cite journal |author1=Savoca PE |author2=Longo WE |author3=Zucker KA | year = 1990 | title = The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study | journal = Ann Surg | volume = 211 | issue = 4| pages = 433–7 | pmid=2322038 | pmc=1358029 | doi=10.1097/00000658-199004000-00009|display-authors=etal}}</ref><ref name=":1" />  Patients are more likely to have yellowing of the skin (jaundice) than in calculous cholecystitis.<ref name=":0">{{Cite book|title=Acute Care Surgery: Imaging Essentials for Rapid Diagnosis|last1=Butler|first1=Kathryn|last2=Harisinghani|first2=Mukesh|publisher=McGraw-Hill Education|year=2015|isbn=978-0-07-183120-8|chapter=Chapter 15: Acute Cholecystitis}}</ref> Ultrasonography or computed tomography often shows an immobile, enlarged gallbladder.<ref name=":1" /> Treatment involves immediate antibiotics and cholecystectomy within 24–72 hours.<ref name=":0" />

=== Chronic cholecystitis ===
Chronic cholecystitis occurs after repeated episodes of acute cholecystitis and is almost always due to gallstones.<ref name=":1" /> Chronic cholecystitis may be asymptomatic, may present as a more severe case of acute cholecystitis, or may lead to a number of complications such as [[gangrene]], [[perforation]], or [[fistula]] formation.<ref name=":1" /><ref name=":2" />

[[Xanthogranulomatous inflammation|Xanthogranulomatous]] cholecystitis (XGC) is a rare form of chronic cholecystitis which mimics gallbladder cancer although it is not cancerous.<ref name="Makino09">{{cite journal |vauthors = Makino I, Yamaguchi T, Sato N, Yasui T, Kita I |title = Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET |journal = World J. Gastroenterol. |volume = 15 |issue = 29 |pages = 3691–3 |date = August 2009 |pmid = 19653352 |pmc = 2721248 |doi = 10.3748/wjg.15.3691 |doi-access = free }}</ref><ref name="Rao05">{{cite journal | vauthors = Rao RV, Kumar A, Sikora SS, Saxena R, Kapoor VK | title = Xanthogranulomatous cholecystitis: differentiation from associated gall bladder carcinoma | journal = Trop Gastroenterol | volume = 26 | issue = 1 | pages = 31–3 | year = 2005 | pmid = 15974235 }}</ref> It was first reported in the medical literature in 1976 by McCoy and colleagues.<ref name="Makino09" /><ref name="McCoy76">{{cite journal | vauthors = McCoy JJ, Vila R, Petrossian G, McCall RA, Reddy KS | title = Xanthogranulomatous cholecystitis. Report of two cases | journal = J S C Med Assoc | volume = 72 | issue = 3 | pages = 78–9 | date = March 1976 | pmid = 1063276}}</ref>

==Mechanism==
Blockage of the cystic duct by a gallstone causes a buildup of bile in the [[gallbladder]] and increased pressure within the gallbladder. Concentrated bile, pressure, and sometimes bacterial infection irritate and damage the gallbladder wall, causing inflammation and swelling of the gallbladder.<ref name=NEJM2008/> Inflammation and swelling of the gallbladder can reduce normal blood flow to areas of the gallbladder, which can lead to [[necrosis|cell death]] due to [[ischemia|inadequate oxygen]].<ref name=":1" />

== Diagnosis ==
The diagnosis of cholecystitis is suggested by the history (abdominal pain, nausea, vomiting, fever) and physical examinations in addition to laboratory and ultrasonographic testing. [[Boas's sign]], which is pain in the area below the right scapula, can be a symptom of acute cholecystitis.<ref>{{cite web  | title = Boas' sign  | publisher = GPnotebook  | url = http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1811546110  | format = web  | access-date = 2007-01-21  | url-status = live  | archive-url = https://web.archive.org/web/20070207032943/http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1811546110  | archive-date = 2007-02-07  }}</ref>

=== Blood tests ===
In someone suspected of having cholecystitis, blood tests are performed for markers of inflammation (e.g. [[complete blood count]], [[C-reactive protein]]), as well as [[bilirubin]] levels in order to assess for bile duct blockage.<ref name=":2" /> Complete blood count typically shows an [[leukocytosis|increased white blood count]] (12,000–15,000/mcL).<ref name=":2" /> C-reactive protein is usually elevated although not commonly measured in the United States.<ref name=NEJM2008/> Bilirubin levels are often mildly elevated (1–4&nbsp;mg/dL).<ref name=":2" /> If bilirubin levels are more significantly elevated, alternate or additional diagnoses should be considered such as gallstone blocking the common bile duct ([[common bile duct stone]]).<ref name=NEJM2008/> Less commonly, blood [[aminotransferases]] are elevated.<ref name=":1" /> The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder.<ref>{{cite book |url= https://www.ncbi.nlm.nih.gov/books/NBK425/ | title= Aminotransferases |via= National Center for Biotechnology Information, U.S. National Library of Medicine | year= 1990 | publisher= Butterworths | pmid= 21250265 | isbn= 978-0-409-90077-4 |access-date= 27 June 2021| last1= Vroon | first1= D. H. | last2= Israili | first2= Z. | last3= Walker | first3= H. K. | last4= Hall | first4= W. D. | last5= Hurst | first5= J. W. }}</ref>

=== Imaging ===
Right upper quadrant abdominal ultrasound is most commonly used to diagnose cholecystitis.<ref name=NEJM2008 /><ref name="pmid7979854">{{cite journal |vauthors = Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, Horangic N, Malet PF, Schwartz JS |title=Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease |journal = Arch. Intern. Med. |volume = 154 |issue = 22 |pages = 2573–81 |date = November 1994 |pmid = 7979854 |doi = 10.1001/archinte.154.22.2573 }}</ref><ref name="pmid3893388">{{cite journal |vauthors = Fink-Bennett D, Freitas JE, Ripley SD, Bree RL |title = The sensitivity of hepatobiliary imaging and real-time ultrasonography in the detection of acute cholecystitis |journal = Arch Surg |volume = 120 |issue = 8 |pages = 904–6 |date = August 1985 |pmid = 3893388 |doi = 10.1001/archsurg.1985.01390320028004 }}</ref> Ultrasound findings suggestive of acute cholecystitis include gallstones, pericholecystic fluid (fluid surrounding the gallbladder), gallbladder wall thickening (wall thickness over 3&nbsp;mm),<ref name="van Breda VriesmanEngelbrecht2007">{{cite journal|last1=van Breda Vriesman|first1=Adriaan C.|last2=Engelbrecht|first2=Marc R.|last3=Smithuis|first3=Robin H. M.|last4=Puylaert|first4=Julien B. C. M.|title=Diffuse Gallbladder Wall Thickening: Differential Diagnosis|journal=American Journal of Roentgenology|volume=188|issue=2|year=2007|pages=495–501|issn=0361-803X|doi=10.2214/AJR.05.1712|pmid=17242260}}</ref> dilation of the bile duct, and [[sonographic Murphy sign|sonographic Murphy's sign]].<ref name=":1" /> Given its higher sensitivity, [[Cholescintigraphy|hepatic iminodiacetic acid]] (HIDA) scan can be used if ultrasound is not diagnostic.<ref name=":1" /><ref name=":2" /> [[CT scan]] may also be used if complications such as perforation or gangrene are suspected.<ref name=":2" />

<gallery>

File:Ultrasonography of cholecystitis.jpg|[[Abdominal ultrasonography]] showing gallstones, wall thickening and fluid around the gall bladder
File:Ultrasonography of sludge and gallstones, annotated.jpg|Gallstones and [[biliary sludge]], but the gallbladder wall is not clearly thickened, with no edema in the pericholecystic fat, thus not cholecystitis.
File:Pacutecholecystitits.png|Acute cholecystitis as seen on ultrasound. The closed arrow points to gallbladder wall thickening. Open arrow points to stones in the GB
File:GBthick,GS,largeMark.png|Acute cholecystitis with gallbladder wall thickening, a large gallstone, and a large gallbladder
File:UOTW 30 - Ultrasound of the Week 1.webm|Significant gallbladder wall thickening<ref name=UOTW30>{{cite web|title=UOTW #30 - Ultrasound of the Week|url=https://www.ultrasoundoftheweek.com/uotw-30/|website=Ultrasound of the Week|access-date=27 May 2017|date=23 December 2014|url-status=live|archive-url=https://web.archive.org/web/20170509113325/https://www.ultrasoundoftheweek.com/uotw-30/|archive-date=9 May 2017}}</ref>
File:UOTW 30 - Ultrasound of the Week 2.webm|Significant gallbladder wall thickening<ref name=UOTW30/>
</gallery>

===Histopathology===
[[Histopathology]] is indicated if preoperative imaging and/or [[gross examination]] gives a suspicion of [[gallbladder cancer]].<ref name="TalrejaAli2016">{{cite journal|last1=Talreja|first1=Vikash|last2=Ali|first2=Aun|last3=Khawaja|first3=Rabel|last4=Rani|first4=Kiran|last5=Samnani|first5=Sunil Sadruddin|last6=Farid|first6=Farah Naz|title=Surgically Resected Gall Bladder: Is Histopathology Needed for All?|journal=Surgery Research and Practice|volume=2016|year=2016|pages=1–4|issn=2356-7759|doi=10.1155/2016/9319147|pmid=27123469|pmc=4829732|doi-access=free}}</ref>
<gallery>

File:Gross pathology of gallbladder carcinoma.jpg|[[Gross examination]] of gallbladder carcinoma, with a prominent nodule.
File:Histopathology of gallbladder carcinoma.jpg|[[Histopathology]] of gallbladder carcinoma, with marked nuclear pleomorphism.
File:Histopathology of eosinophilic cholecystitis.jpg|Histopathology of eosinophilic cholecystitis
File:Gross pathology of cholesterolosis.jpg|Gross examination of [[Cholesterolosis of gallbladder|gallbladder cholesterolosis]], with yellow streaks of cholesterol deposition.
File:Histopatholgoy of acute gangrenous cholecystitis.jpg|Histopathology of acute gangrenous cholecystitis, showing necrosis, neutrophils and partially sloughed off mucosa.
</gallery>

=== Differential diagnosis ===
Many other diagnoses can have similar symptoms as cholecystitis. Additionally the symptoms of chronic cholecystitis are commonly vague and can be mistaken for other diseases.  These alternative diagnoses include but are not limited to:<ref name=":2" />
* [[Perforated peptic ulcer]]
* [[Acute pancreatitis]]
* [[Liver abscess]]
* [[Pneumonia]]
* [[Myocardial ischemia]]
* [[Hiatal hernia]]
* Biliary colic
* [[Gallstone#Choledocholithiasis|Choledocholithiasis]]
* [[Cholangitis]]
* [[Appendicitis]]
* Colitis
* Acute peptic ulcer exacerbation
* [[Amoebic liver abscess]]
* Acute [[intestinal obstruction]]
* [[renal colic|Kidney stone]]
* Biliary ascariasis<ref>{{cite journal|last1=Kuzu|first1=MA|last2=Oztürk|first2=Y|last3=Ozbek|first3=H|last4=Soran|first4=A|title=Acalculous cholecystitis: ascariasis as an unusual cause.|journal=Journal of Gastroenterology|date=October 1996|volume=31|issue=5|pages=747–9|pmid=8887047|doi=10.1007/bf02347629|s2cid=19385620}}<!--|access-date=19 March 2015--></ref>

== Treatment ==
[[File:Laprascopy-Roentgen.jpg|thumb|X-ray during laparoscopic cholecystectomy]]

===Surgery===
For most people with acute cholecystitis, the treatment of choice is surgical removal of the gallbladder, laparoscopic [[cholecystectomy]].<ref name="Strasberg,2006">{{cite journal | author = Strasberg SM | title = Acute Calculous Cholecystitis | journal = New England Journal of Medicine | volume = 358 | issue = 26 | pages = 2804–2811 | year = 2008 | pmid = 18579815 | doi = 10.1056/NEJMcp0800929 }}</ref> Laparoscopic cholecystectomy is performed using several small incisions located at various points across the abdomen. Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared to open cholecystectomy (using a large incision in the right upper abdomen under the rib cage). People undergoing laparoscopic surgery report less incisional pain postoperatively as well as having fewer long-term complications and less disability following the surgery.<ref name="Velanovich,2000">{{cite journal | author = Velanovich V | title = Laparoscopic vs open surgery: A preliminary comparison of quality-of-life outcomes | journal = Surgical Endoscopy | volume = 14 | issue = 1 | pages = 16–21 | year = 2000 | pmid = 10653229 | doi = 10.1007/s004649900003 | s2cid = 26868091 }}</ref><ref name="Chen,2005">{{cite journal | vauthors = Chen L, Tao SF, Xu Y, Fang F, Peng SY | title = Patients' quality of life after laparoscopic or open cholecystectomy | journal = Journal of Zhejiang University Science | volume = 6B | issue = 7 | pages = 678–681 | year = 2005 | pmid = 15973772 | pmc = 1389804 | doi = 10.1631/jzus.2005.B0678 }}</ref> Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.<ref name="Richards,2003">{{cite journal | vauthors = Richards C, Edwards J, Culver D, Emori TG, Tolson J, Gaynes R | title = Does Using a Laparoscopic Approach to Cholecystectomy Decrease the Risk of Surgical Site Infection? | journal = Annals of Surgery | volume = 237 | issue = 3 | pages = 358–362 | year = 2003 | pmid = 12616119 | pmc = 1514308 | doi = 10.1097/01.SLA.0000055221.50062.7A }}</ref>

During the days prior to laparoscopic surgery, studies showed that outcomes were better following early removal of the gallbladder, preferably within the first week.<ref name="Banz,2011">{{cite journal | vauthors = Banz V, Gsponer T, Candinas D, Güller U | title = Population-Based Analysis of 4113 Patients with Acute Cholecystitis | journal = Annals of Surgery | volume = 254 | issue = 6 | pages = 964–970 | year = 2011 | pmid = 21817893 | doi = 10.1097/SLA.0b013e318228d31c | s2cid = 875668 }}</ref> Early laparoscopic cholecystectomy (within 7 days of visiting a doctor with symptoms) as compared to delayed treatment (more than 6 weeks) may result in shorter hospital stays and a decreased risk of requiring an emergency procedure.<ref name=Gurusamy2013 /> There is no difference in terms of negative outcomes including bile duct injury or conversion to open [[cholecystectomy]].<ref name=Gurusamy2013>{{Cite journal|last1=Gurusamy|first1=Kurinchi Selvan|last2=Davidson|first2=Christopher|last3=Gluud|first3=Christian|last4=Davidson|first4=Brian R.|date=2013-06-30|title=Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis|journal=The Cochrane Database of Systematic Reviews|issue=6|article-number=CD005440|doi=10.1002/14651858.CD005440.pub3|issn=1469-493X|pmid=23813477}}</ref> For early cholecystectomy, the most common reason for conversion to open surgery is inflammation that hides [[cystohepatic triangle|Calot's triangle]]. For delayed surgery, the most common reason was fibrotic adhesions.<ref name=Gurusamy2013 />

===Other===
[[File:X-ray with contrast of a percutaneous gallbladder drain.jpg|thumb|[[Radiography]] of a percutaneous drainage catheter (yellow arrow). In this control, the instilled [[radiocontrast agent|radiocontrast]] is filling out the gallbladder (red arrow), where the filling defects are gallstones. The [[cystic duct]] (blue arrow) is tortuous, the common bile duct (green arrow) is mildly dilated but patent, with tapering at [[ampulla Vateri]] (white arrow), but without obstruction. Contrast was seen extending into the duodenum (orange arrows), demonstrating open passage through the bile ducts.<ref>{{cite journal|last1=Padilla|first1=Rebekah M|last2=Hulsberg|first2=Paul C|last3=Soule|first3=Erik|last4=Harmon|first4=Taylor S|last5=Eadie|first5=Erik|last6=Hood|first6=Preston|last7=Shabandi|first7=Michael|last8=Matteo|first8=Jerry|title=Against the Odds: A Novel Technique to Perform Cholangiography from a Percutaneous Approach through the Cystic Duct|journal=Cureus|year=2018|volume=10|issue=11|article-number=e3577|issn=2168-8184|doi=10.7759/cureus.3577|doi-access=free |pmid=30656081|pmc=6333255}}</ref>]]
Supportive measures may be instituted prior to surgery. These measures include fluid resuscitation. Intravenous [[opioids]] can be used for pain control.<ref>{{cite web |url=https://www.lecturio.com/concepts/cholecystitis/| title=Cholecystitis|website=The Lecturio Medical Concept Library |access-date= 8 July 2021}}</ref>

[[Antibiotic]]s are often not needed.<ref>{{cite journal|last1=van Dijk|first1=AH|last2=de Reuver|first2=PR|last3=Tasma|first3=TN|last4=van Dieren|first4=S|last5=Hugh|first5=TJ|last6=Boermeester|first6=MA|title=Systematic review of antibiotic treatment for acute calculous cholecystitis.|journal=The British Journal of Surgery|date=30 March 2016|pmid=27027851|doi=10.1002/bjs.10146|volume=103|issue=7|pages=797–811|s2cid=205507793}}</ref>

In cases of severe inflammation, shock, or if the person has higher risk for general anesthesia (required for [[cholecystectomy]]), an [[interventional radiology|interventional radiologist]] may insert a [[percutaneous]] drainage catheter into the gallbladder (percutaneous [[cholecystostomy]] tube) and treat the person with antibiotics until the acute inflammation resolves. A [[cholecystectomy]] may then be warranted if the person's condition improves.<ref>{{cite web |url= https://www.lecturio.com/concepts/acute-cholangitis/ | title= Acute Cholangitis | website= The Lecturio Medical Concept Library |access-date= 27 June 2021}}</ref>

[[Homeopathic]] approaches to treating cholecystitis have not been validated by evidence and should not be used in place of surgery.<ref>{{cite book|author=Tuomela, R|title=Rational Changes in Science |chapter=Science, Protoscience, and Pseudoscience |publisher=Springer|year=1987|isbn=978-94-010-8181-8|veditors=Pitt JC, Marcello P|series=Boston Studies in the Philosophy of Science|volume=98|pages=83–101|doi=10.1007/978-94-009-3779-6_4|author-link=Raimo Tuomela}}</ref>

== Epidemiology ==
Cholecystitis accounts for 3–10% of cases of abdominal pain worldwide.<ref name=":12">{{Cite journal|last1=Kimura|first1=Yasutoshi|last2=Takada|first2=Tadahiro|last3=Kawarada|first3=Yoshifumi|last4=Nimura|first4=Yuji|last5=Hirata|first5=Koichi|last6=Sekimoto|first6=Miho|last7=Yoshida|first7=Masahiro|last8=Mayumi|first8=Toshihiko|last9=Wada|first9=Keita|date=2016-12-12|title=Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines|journal=Journal of Hepato-Biliary-Pancreatic Surgery|volume=14|issue=1|pages=15–26|doi=10.1007/s00534-006-1152-y|issn=0944-1166|pmc=2784509|pmid=17252293}}</ref> Cholecystitis caused an estimated 651,829 emergency department visits and 389,180 hospital admissions in the US in 2012.<ref name=":02">{{Cite journal|last1=Peery|first1=Anne F.|last2=Crockett|first2=Seth D.|last3=Barritt|first3=Alfred S.|last4=Dellon|first4=Evan S.|last5=Eluri|first5=Swathi|last6=Gangarosa|first6=Lisa M.|last7=Jensen|first7=Elizabeth T.|last8=Lund|first8=Jennifer L.|last9=Pasricha|first9=Sarina|title=Burden of Gastrointestinal, Liver, and Pancreatic Diseases in the United States|journal=Gastroenterology|volume=149|issue=7|pages=1731–1741.e3|doi=10.1053/j.gastro.2015.08.045|pmc=4663148|pmid=26327134|year=2015}}</ref> The 2012 US mortality rate was 0.7 per 100,000 people.<ref name=":02" /> The frequency of cholecystitis is highest in people age 50–69 years old.<ref name=":12" />
{{-}}

==References==
{{Reflist}}

==External links==
{{Medical condition classification and resources|
  ICD10          = {{ICD10|K|81||k|80}} |
  ICD9           = {{ICD9|575.0}}, {{ICD9|575.1}} |
  ICDO           = |
  OMIM           = |
  MedlinePlus    = 000264 |
  eMedicineSubj  = med |
  eMedicineTopic = 346 |
  DiseasesDB     = 2520 |
  MeshID         = D002764 |
}}

{{Gastroenterology}}

{{Authority control}}

[[Category:Gallbladder disorders]]
[[Category:Hepatology]]
[[Category:Inflammations]]
[[Category:IgG4-related disease]]
[[Category:Articles containing video clips]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Wikipedia emergency medicine articles ready to translate]]