Gastroenterology & General Surgery
Cholécystite | Clinique Omicron Québec
Cholecystitis is an inflammation of the gallbladder - a pear-shaped organ nestling beneath the liver, whose function is to concentrate and store bile produced by the liver before releasing it into the duodenum during meals to aid fat digestion. In over 90 % of cases, acute cholecystitis is secondary to blockage of the cystic duct by one or more gallstones (vesicular lithiasis), thus constituting acute lithiasic cholecystitis - a frequent and potentially serious complication of vesicular lithiasis that affects around 10 to 15 % of the adult population in Western countries. In Canada, vesicular lithiasis is one of the most common digestive pathologies, with an estimated prevalence of 15-20 % in adults over 40, and cholecystectomy (surgical removal of the gallbladder) is among the most frequently performed surgical procedures in the country. Acute cholecystitis differs from simple biliary colic - transient pain caused by temporary obstruction of the cystic duct, resolving spontaneously in less than 6 hours - in that the pain persists beyond 6 hours, with fever and local inflammatory signs indicating genuine inflammation of the gallbladder wall. Acute alithiasic cholecystitis (without calculi), which accounts for 5 to 10 % of cases, occurs in contexts of severe physiological stress - intensive care, major surgery, extensive burns, sepsis, prolonged parenteral nutrition - and is associated with a higher mortality than the lithiasic form. Chronic cholecystitis, on the other hand, results from repeated episodes of inflammation leading to progressive fibrosis of the vesicular wall, with recurrent, less intense but persistent pain. The management of acute cholecystitis is based on hospitalization, antibiotic therapy and early laparoscopic cholecystectomy - ideally performed within 24 to 72 hours of diagnosis, which is associated with the best clinical outcome according to current data.
Classification and clinical forms
| Clinical form | Mechanism / Context | Key features |
|---|---|---|
| Simple biliary colic | Transient obstruction of the cystic duct by a calculus | Right hypochondrium pain of rapid onset (often postprandial after a fatty meal), intense, without fever or hyperleukocytosis; lasts less than 6 hours and resolves spontaneously when stone disengages; echo confirms lithiasis; treatment: analgesics and elective cholecystectomy scheduled; often precedes acute cholecystitis |
| Acute lithiasis cholecystitis | Persistent obstruction of the cystic duct by calculus + parietal inflammation | Most frequent form (90-95 % of cholecystitis); pain persisting > 6 hours, fever, positive Murphy's sign, hyperleukocytosis, elevated CRP; distended and inflamed gallbladder on ultrasound; treatment: hospitalization, IV antibiotic therapy, early laparoscopic cholecystectomy (24-72 h) |
| Acute alithiasic cholecystitis | Biliary stasis and parietal ischemia without calculi | 5-10 % of cholecystitis; intensive care patients (sepsis, major surgery, burns, prolonged parenteral nutrition, trauma); difficult diagnosis in the intensive care setting (patient often sedated, signs masked); high mortality (30-50 %) if diagnosis delayed; treatment: cholecystectomy or percutaneous cholecystostomy depending on patient's condition. |
| Chronic cholecystitis | Recurrent inflammation with progressive wall fibrosis | Repeated episodes of biliary colic or incompletely treated acute cholecystitis; thickened, fibrous vesicular wall on imaging; chronic dyspeptic symptoms (bloating, fat intolerance, postprandial nausea); treatment: elective laparoscopic cholecystectomy |
| Emphysematous cholecystitis | Infection with gas-producing anaerobic germs | Rare but severe form; presence of gas in the vesicular wall or lumen on CT; agents: Clostridium spp, E. coli, Klebsiella ; frequent in diabetic and immunocompromised patients; high risk of gangrene and perforation; absolute surgical emergency |
| Gangrenous cholecystitis and perforation | Serious complication of untreated acute cholecystitis | Ischemic necrosis of the vesicular wall with risk of perforation and biliary peritonitis; risk factors: diabetes, delayed diagnosis, advanced age, immunosuppression; pain may paradoxically diminish during gangrene (necrosis of nerve endings) before resuming violently during perforation; absolute surgical emergency. |
Risk factors for biliary lithiasis and cholecystitis
The classic mnemonic rule of the «5Fs» (Fat, Female, Fertile, Forty, Family) summarizes the main risk factors for cholesterolic biliary lithiasis, the most common form in Western countries:
- Female: estrogens increase biliary cholesterol secretion and reduce vesicular motility; risk 2 to 3 times higher in women before the menopause; pregnancy (progesterone-induced vesicular stasis), oral contraception and hormone replacement therapy for menopause further increase the risk.
- Obesity and metabolic syndrome: biliary hypersecretion of cholesterol in proportion to body fat; rapid weight loss (bariatric surgery, very low-calorie diets) - paradoxically also a risk factor through massive cholesterol mobilization and vesicular stasis in the event of prolonged fasting
- Advanced age: the prevalence of biliary lithiasis increases progressively with age - from 10 % at age 40 to over 40 % after age 70; progressive reduction in biliary cholesterol solubility with age
- Family history of biliary lithiasis: significant heritability of cholesterolic lithiasis (ABCG8 transporter mutations in particular); particularly high prevalence in certain populations (Amerindians - prevalence up to 70-80 % in Pima women, Chileans)
- Diabetes mellitus and insulin resistance: reduced vesicular contractility and biliary cholesterol hypersecretion; increased risk of acute alithiasic cholecystitis and emphysematous cholecystitis
- Ileal diseases and intestinal resection: bile acid reabsorption takes place in the terminal ileum - ileal Crohn's disease, ileal resection or intestinal bypass reduce the bile acid pool, favoring biliary cholesterol precipitation (cholesterol lithiasis); black pigment lithiasis is common in chronic hemolysis (sickle cell disease, spherocytosis, thalassemia)
- Lithogenic drugs: fibrates (increase biliary cholesterol secretion), ceftriaxone (precipitation in bile - lithiasis reversible on discontinuation), octreotide (somatostatin analogues - reduced vesicular motility), ciclosporin
Symptoms
- Right hypochondrium or epigastric pain: intense, constant pain (not colic despite common terminology), progressive onset over 30 to 60 minutes, classically radiating to the right shoulder or right subscapular region (phrenic irradiation); typically triggered within 1 to 3 hours of a high-fat meal; persisting beyond 6 hours in acute cholecystitis (vs. rapid resolution in simple biliary colic)
- Fever: temperature generally between 38 and 39°C in acute uncomplicated cholecystitis; high fever (> 39°C), chills and septicemic state suggestive of a complication (empyema, gangrene, perforation, associated angiocholitis).
- Nausea and vomiting: frequent, often associated with pain; vomiting does not relieve pain (unlike gastric pain).
- Positive Murphy's sign: provoked pain on deep palpation of the right hypochondrium with inspiratory blockage - the most specific clinical sign of acute cholecystitis (specificity 79 %, sensitivity 65 %); the ultrasound version (ultrasound Murphy's sign) has better diagnostic value
- Right hypochondrium tense or contracture: sign of local peritoneal distress, suggesting a complication (biliary peritonitis, perforation).
- Icterus (jaundice): yellow coloration of the sclerae and skin due to hyperbilirubinemia - not expected in simple acute cholecystitis; its presence suggests stone migration in the main bile duct with obstruction (choledocholithiasis) or angiocholitis (Charcot triad: pain + fever + jaundice).
- Palpable mass in the right hypochondrium: distended and tense gallbladder palpable in 30 to 40 % cases of acute cholecystitis; vesicular hydrops in chronic forms (distended gallbladder with clear bile due to obstruction without inflammation)
ℹ️
Charcot's triad - right hypochondral pain, fever with chills and jaundice - is pathognomonic of acute angiocholitis (infection of the main bile duct), a serious complication of choledocholithiasis as distinct from cholecystitis. Reynolds pentad adds confusion and septic shock to this triad - a life-threatening picture of severe angiocholitis requiring emergency endoscopic biliary drainage (ERCP) and IV antibiotic therapy without delay.
Diagnosis
- Abdominal ultrasound : first-line reference test - sensitivity 88-94 % and specificity 78-80 % for acute cholecystitis ; visualizes vesicular calculi (hyperechoic with posterior shadow cone), vesicular parietal thickening (> 3 mm - cardinal sign), perivesicular edema (perivesicular fluid border), ultrasound Murphy's sign (pain caused by the probe in contact with the vesicle) and vesicular distension; rapid, non-irradiating examination, available as an emergency procedure
- Biological work-up : CBC (neutrophil hyperleukocytosis - > 10,000/mm³ in 85 % of cases); CRP (marker of inflammation - elevated in cholecystitis; very high CRP with high fever suggests a complication) ; complete liver workup (ALT, ASAT, GGT, PAL, total and direct bilirubin) - hepatic cytolysis or associated cholestasis suggest choledocholithiasis or angiocholitis; lipemia (to rule out associated acute pancreatitis - biliary lithiasis is the main cause of acute pancreatitis); blood cultures if high fever or chills
- Abdominal CT scan with injection (CT): indicated if ultrasound is inconclusive, if a complication is suspected (gangrene, perforation, emphysema, perivesicular abscess) or if a differential diagnosis must be eliminated; shows parietal thickening with contrast, complications (perforation, abscess, intraparietal gas) and adenopathies; better visualization of the bile ducts than ultrasound
- hepatobiliary MRI and cholangio-MRI (CPRM): reference examination for biliary tract assessment (choledocholithiasis, biliary stenosis) - non-irradiating, does not require injection of contrast medium for visualization of gallstones; indicated if there is any doubt about associated choledocholithiasis prior to surgery
- HIDA biliary scintigraphy: visualizes vesicular function and biliary transit; useful for diagnosing acute alithiasic cholecystitis (absence of vesicular filling by tracer despite a permeable main biliary tract); not widely used as a first-line treatment due to limited availability.
- Tokyo Diagnostic Criteria (TG18/TG13): international standardized criteria for diagnosis and grading of severity of acute cholecystitis (grade I: mild, grade II: moderate, grade III: severe with organ failure) to guide treatment decisions
Treatment
- Hospitalization and general measures: fasting (NPO), analgesia (antispasmodics, IV NSAIDs or opioids depending on intensity), antiemetics, intravenous hydration; close clinical and biological monitoring (temperature, pain, CBC, CRP, liver function tests).
- Intravenous antibiotic therapy: indicated from the diagnosis of confirmed acute cholecystitis; covers enterobacteria (E. coli, Klebsiella) and anaerobes depending on the context; first-line regimen in Quebec: cefazolin IV or ampicillin-sulbactam IV for mild to moderate forms (grade I-II); piperacillin-tazobactam or carbapenem if patient immunocompromised, diabetic, severe form (grade III) or suspected resistance; duration: 24-48 hours post-cholecystectomy for uncomplicated forms; longer if infectious complication documented.
- Early laparoscopic cholecystectomy (24-72 hours): gold-standard curative treatment - superior to delayed cholecystectomy (6-8 weeks) according to current meta-analysis data; reduced total hospital stay, complications and risk of recurrence during the waiting period; laparoscopic technique in > 90 % of cases (conversion to open laparotomy if complex anatomy, adhesions, complication); cholecystectomy with 4 or 3 trocars depending on centers; operative time: 45-90 minutes
- Percutaneous drainage cholecystostomy: alternative to surgery for patients at very high operative risk (grade III, severe comorbidities, advanced age, ASA IV); transcutaneous radiological drainage of the gallbladder under ultrasound or CT guidance; temporization treatment to stabilize the patient before a deferred elective cholecystectomy or as definitive treatment in inoperable patients.
- Laparoscopic elective cholecystectomy for chronic cholecystitis and recurrent biliary colic: surgical indication for all symptomatic biliary lithiasis to prevent complications (acute cholecystitis, choledocholithiasis, acute biliary pancreatitis, gallbladder cancer); waiting list varies by province and facility
- Management of associated choledocholithiasis: if stones in the main bile duct (choledocholithiasis) - endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy for stone removal before or after cholecystectomy; intraoperative cholangiography or laparoscopic exploration of the main bile duct.
- Post-cholecystectomy diet: the majority of patients tolerate a normal diet after cholecystectomy; temporary avoidance of very fatty meals in the first few weeks; postprandial diarrhea (post-cholecystectomy syndrome caused by continuous discharge of bile into the duodenum) is transient in the majority of cases.
Signs requiring urgent consultation or 911
Dial 911 or go immediately to the emergency room if you experience: intense, persistent abdominal pain in the right hypochondrium or epigastrium, especially if associated with fever and chills, jaundice, hypotension, confusion or a rigid abdomen (wooden belly). These signs suggest complicated acute cholecystitis (gangrene, perforation, empyema), severe angiocholitis (Reynolds pentad) or acute biliary pancreatitis - life-threatening medical and surgical emergencies. Any recurrent postprandial abdominal pain in the right hypochondrium, even without fever, should prompt a medical consultation and abdominal ultrasound within a reasonable timeframe.
For a medical consultation, a request for an abdominal ultrasound or a referral to a general surgeon, Clinique Omicron offers consultations in our Quebec branches as well as via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron physicians assess right hypochondrium pain suggestive of biliary pathology, prescribe abdominal ultrasound and first-line biologic work-up, and refer to partner general surgeons based on results and clinical urgency. Consultations are available in our Quebec branches, as well as via telemedicine for the entire province. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not replace the advice of a qualified healthcare professional. Acute cholecystitis is a medical and surgical emergency requiring immediate hospital evaluation.
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