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Gallstones and acute cholecystitis
A stone passing through the gallbladder neck causes pain that settles (biliary colic), while a stone that stays impacted causes inflammation; acute cholecystitis is treated with early laparoscopic cholecystectomy, not "cool it down and come back in two months".
Why it matters in the exam
Questions almost always start with the distinction between biliary colic and cholecystitis: the duration of pain, fever, Murphy's sign and the blood count. Then they ask about the right test — ultrasound first, and a HIDA scan when the diagnosis is unclear — and about the timing of surgery. The expected answer is early laparoscopic cholecystectomy during the same admission rather than a delayed "cold" operation, because early surgery shortens the stay and prevents recurrences without increasing complications.
A second group of questions covers special patients and complications: a ventilated ICU patient with acalculous cholecystitis, an older diabetic with gas in the gallbladder wall, a patient unfit for surgery whose gallbladder is drained through the skin, and an older woman with small bowel obstruction caused by a stone that has passed into the bowel. Candidates are also asked when asymptomatic stones justify surgery (almost never) and when a gallbladder polyp justifies cholecystectomy. Deep jaundice is not part of simple cholecystitis and should raise suspicion of a common bile duct stone.
Key points
- Colic = pain settling within less than 6 hours; cholecystitis = persistent pain with fever and Murphy's sign.
- Ultrasound is the first test; HIDA is the most sensitive test when the diagnosis is unclear.
- Acute cholecystitis: antibiotics and early laparoscopic cholecystectomy, ideally within 72 hours.
- Unfit for surgery, or grade III that has not stabilised: percutaneous cholecystostomy.
- Acalculous cholecystitis in the critically ill; emphysematous cholecystitis in diabetics — urgent surgery.
Summary table
| Situation | Clinical picture | Decisive test | Treatment |
|---|---|---|---|
| Asymptomatic stones | Incidental finding on ultrasound | No further test needed | Observation; in most cases no surgery |
| Biliary colic | Right upper quadrant pain after a meal, settling within less than 6 hours, no fever | Ultrasound: stones, normal wall | Elective laparoscopic cholecystectomy |
| Acute calculous cholecystitis | Persistent pain, fever, Murphy's sign, leucocytosis | Ultrasound: thick wall, pericholecystic fluid, sonographic Murphy; HIDA if unclear | Antibiotics and early laparoscopic cholecystectomy, ideally within 72 hours |
| Acalculous cholecystitis | Critically ill ICU patient, after burns, trauma or parenteral nutrition | Ultrasound: distended gallbladder with a thick wall | Antibiotics; percutaneous cholecystostomy if unfit for surgery |
| Emphysematous cholecystitis | Diabetic or older patient, rapid course | CT: gas in the gallbladder wall | Urgent surgery and broad antibiotics covering anaerobes |
| Gallstone ileus | Small bowel obstruction in an older woman | CT: pneumobilia, obstruction and an ectopic stone (Rigler's triad) | Enterotomy and stone extraction |
A free exam question
What is the most common cause of chronic pancreatitis?
- A. Gallbladder stones
- B. High level of calcium in the blood
- C. High blood triglyceride levels
- D. Alcoholism
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Sources
- Tokyo Guidelines 2018 (TG18) for acute cholecystitis, 2018 — Diagnostic criteria, severity grading and flowchart for management
- WSES guidelines on acute calculous cholecystitis, 2020 — Timing of cholecystectomy and the high-risk patient
- Sabiston Textbook of Surgery, 21st edition (2022) — The Biliary System
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.