Acute cholecystitis

The gallbladder is a small pouch tucked under the liver that works as a holding tank: it collects bile, concentrates it and squeezes it into the gut when a fatty meal arrives. Acute cholecystitis is inflammation of its wall, and it builds up over hours. Most often it starts with a stone wedged in the narrow outlet of the gallbladder, though it also happens without stones. It does not settle on its own and complications move fast, which is why it is treated in hospital.

What is happening inside the gallbladder

The way out of the gallbladder, the cystic duct, is very narrow. When a stone or thick biliary sludge plugs it, the bile has nowhere to go. Pressure builds, the wall stretches and swells, and its blood supply worsens. On that background gut bacteria settle in easily and the inflammation turns purulent.

That is what separates cholecystitis from an ordinary attack of biliary colic. In colic the stone shifts by itself: the pain eases within a couple of hours, there is no fever, and the person is left more or less well. In cholecystitis the plug stays put, the pain does not let up, fever appears, and from there a doctor is needed.

What it feels like

The main thing is pain under the right ribs, often spreading to the right shoulder blade or the right shoulder. It is steady rather than coming in waves, lasts for hours, and barely responds to the usual home remedies. An attack often begins an hour or two after a large fatty meal, sometimes at night.

• the upper right side of the belly is tender to the touch and taking a deep breath hurts;
• fever and chills;
• nausea and vomiting that brings no relief;
• loss of appetite, with even the smell of food becoming unpleasant;
• bloating, with no stool and no wind passing;
• in older people and in people with diabetes the picture can be blunted: no high fever, vague pain, but weakness and confusion instead.

When it cannot wait until morning

Call the emergency number rather than booking an appointment if any of these is added to pain under the right ribs:

• yellow skin and eyes, dark urine, pale stools — a stone may have moved into the main bile duct;
• high fever with heavy shivering together with jaundice — this is how infection of the bile ducts presents, and it is life-threatening;
• pain spreading across the whole abdomen, with the belly turning rigid;
• confusion, drowsiness, cold clammy skin, a fast weak pulse, a drop in blood pressure;
• pain wrapping around into the back with vomiting that will not stop — pancreatitis is possible;
• pain under the right rib lasting more than five or six hours without easing.

While waiting for help, do not put heat on the abdomen: warmth drives the inflammation on. Better not to eat or drink, since urgent surgery may be needed. If you have already taken any medicine, tell the doctor about it.

Stones are not always to blame

Some patients have no stones at all. These cases are the minority, but they run a rougher course. Acalculous cholecystitis develops in seriously ill people: after major surgery, extensive burns or trauma, during sepsis, prolonged feeding through a vein, or severe dehydration. Here the gallbladder suffers not from a blockage but from poor blood flow, and the wall dies off faster.

There are rare but dangerous variants too. In people with poorly controlled diabetes the inflammation is sometimes caused by gas-forming bacteria: the wall breaks down very quickly and the clock runs in hours. Gallbladder cancer is a separate story: it is uncommon, but it not infrequently shows itself as exactly this kind of drawn-out cholecystitis that fails to respond to treatment. That is why a removed gallbladder is always sent for laboratory examination, and it is not worth declining that.

What is done in hospital

The diagnosis starts with an examination: the doctor presses under the right ribs and asks the patient to breathe in, and in cholecystitis that breath triggers a sharp pain. Blood tests follow, to show the inflammation and check the liver, along with an abdominal ultrasound scan, which reveals stones, a thickened gallbladder wall and fluid around it. If the picture is unclear, or a stone in the main duct is suspected, a CT scan or an MR cholangiogram is added.

Treatment in the first days means resting the gallbladder: food is withheld for a while, fluids and painkillers are given into a vein, and antibiotics are started if infection is suspected. That settles the attack but does not remove the cause, so the definitive treatment is taking the gallbladder out. These days surgeons aim to do it without delay, during the same admission, and usually through a few small cuts. If the patient is too unwell for anaesthesia, a thin drain is placed into the gallbladder, the acute inflammation is cooled down, and surgery is revisited later.

Life without a gallbladder is a full one: the liver keeps producing bile, which now flows straight into the gut. For the first few weeks some people notice looser stools and bloating after fatty food; this usually settles by itself within a month or two.

What lowers the risk of stones

There is no complete protection, but the way a person eats and the speed at which their weight changes both affect how likely stones are to form.

• regular meals: long gaps and skipped breakfasts leave bile sitting still;
• enough fibre and vegetable oils, less pastry, sweets and fatty meat;
• losing weight steadily rather than in bursts — crash diets and rapid weight loss themselves push stones to form;
• daily movement, walking at the very least;
• if a scan has already found stones and they are causing attacks, it is worth discussing planned surgery before acute inflammation arrives.

Online consultation for pain under the right ribs

Acute cholecystitis is treated as an inpatient, and a remote appointment does not replace that. But a doctor is useful both before hospital and after it.

• work out whether your pain looks biliary, and say plainly whether to head to emergency care now or whether tests can be planned;
• explain what your blood results and ultrasound report actually mean;
• help you prepare for the conversation about planned gallbladder removal and the questions worth asking the surgeon;
• sort out diet and symptoms after the operation if bowel habit and bloating are not settling;
• review the medicines you take regularly.

If any of the warning signs listed above comes up during the conversation, the doctor will say so straight away and tell you to call for emergency help.

This material is for information only and does not replace medical advice.