Cholecystitis: Symptoms, Types, Causes and Treatment

Cholecystitis is a common yet potentially serious condition involving inflammation of the gallbladder. It can present in a variety of ways, with different underlying causes and treatment strategies. Understanding the clinical features, recognizing the different forms, and knowing the appropriate management pathways are crucial for both patients and healthcare professionals. This article provides a comprehensive overview of cholecystitis, synthesizing the latest research to help you understand its symptoms, types, causes, and treatments.

Symptoms of Cholecystitis

Cholecystitis often sneaks up with pain and discomfort, but its symptoms can range from classic to subtle—especially in certain populations. Recognizing these signs early can make a significant difference in outcomes, particularly because some people, like the elderly, may not display textbook symptoms. Here, we break down the major symptoms and their clinical significance.

Symptom	Typical Feature	Prevalence/Notes	Sources
Abdominal pain	RUQ or epigastric	Common, but may be absent in elderly	1 3 4
Fever	Systemic sign	Only ~44% elderly patients	1 4
Nausea/vomiting	GI symptom	Up to 57% report nausea	1 3
Jaundice	Yellowing of skin/eyes	Uncommon, more in >85 yrs	1 4
Murphy’s sign	RUQ pain with inspiration	Useful clinical test	4
Atypical signs	Chest pain, bradycardia	Rare, can mimic cardiac issues	2

Table 1: Key Symptoms

Recognizing the Classic and Atypical Presentations

Cholecystitis most often presents with pain in the right upper quadrant (RUQ) of the abdomen. This pain may radiate to the back or shoulder and is frequently accompanied by nausea and vomiting. Fever is a classic sign, though not everyone—especially older adults—will have it. In fact, studies show that more than half of geriatric patients are afebrile, and a significant number may not even experience pain at all 1.

Importance of Murphy’s Sign

Murphy’s sign—pain elicited when pressing on the RUQ while the patient inhales deeply—is a classic diagnostic clue. However, its absence does not rule out cholecystitis, particularly in elderly patients or those with atypical presentations 4.

When Symptoms Are Atypical

In rare instances, cholecystitis may cause chest pain and even changes in heart rhythm, mimicking a heart attack. This is due to a vagal reflex known as Cope’s sign and can result in unnecessary cardiac workups if cholecystitis is not considered 2.

Elderly Patients: A Special Note

Older adults often lack classic symptoms. Over 80% of elderly patients with confirmed cholecystitis may not report any abdominal pain, and many do not have elevated white blood cell counts or fever. This makes a high degree of clinical suspicion essential in these populations 1.

Types of Cholecystitis

Cholecystitis is not a one-size-fits-all disease. It encompasses several distinct variants, each with unique causes, risk factors, and clinical implications. Understanding these types helps guide tailored treatment and anticipate complications.

Type	Description	Distinguishing Features	Sources
Calculous	Stone-related; most common	Gallstones obstruct duct	3 9 13
Acalculous	No gallstones	Critically ill patients, rapid course	5 7 9
Emphysematous	Gas-forming bacteria	Higher perforation risk	6
Hemorrhagic	Bleeding within gallbladder	Often linked to anticoagulants	11 13
Eosinophilic	Eosinophil-rich inflammation	Often acalculous, hypersensitivity	8

Table 2: Main Types of Cholecystitis

Calculous Cholecystitis

This is by far the most common type, accounting for about 90–95% of cases. Here, gallstones block the cystic duct, leading to inflammation 3 9. Symptoms are often classic, but complications can occur if the blockage persists.

Acalculous Cholecystitis

Acalculous cholecystitis is less common but more dangerous, frequently affecting critically ill or postoperative patients. Unlike calculous cholecystitis, there are no gallstones. Ischemia, infection, or bile stasis are the typical culprits, and the disease can progress rapidly to gangrene or perforation 5 7 9.

Emphysematous Cholecystitis

This rare form is defined by gas within the gallbladder wall or lumen, produced by specific bacteria (e.g., Clostridia, E. coli). It is more common in males and carries a fivefold higher risk of perforation compared to standard acute cholecystitis, making early identification and intervention critical 6.

Hemorrhagic Cholecystitis

Hemorrhagic cholecystitis involves bleeding into the gallbladder, often due to trauma, gallstones, or more frequently, the use of anticoagulants. It can manifest with typical symptoms or present as gastrointestinal bleeding and may be life-threatening without prompt diagnosis and management 11 13.

Eosinophilic Cholecystitis

An uncommon variant, eosinophilic cholecystitis is characterized by a predominance of eosinophils in the inflammatory infiltrate. It is more often associated with acalculous cases and may represent a hypersensitivity reaction to altered bile or medications 8.

Causes of Cholecystitis

Pinpointing the cause of cholecystitis is essential for effective management. While gallstones are the leading culprit, a variety of factors, from infections to systemic illnesses, can also trigger gallbladder inflammation.

Cause Type	Examples/Details	Special Notes	Sources
Gallstones	Obstruct cystic duct	Most common cause	3 9 13
Infection	Bacteria (E. coli, Klebsiella, etc.)	~50–85% bacterial	10 12
Ischemia	Reduced blood flow (shock, trauma)	Critical illness, burns	5 7 9
Medications	Certain drugs (oral contraceptives, etc.)	May alter bile flow	9
Systemic Illness	Sepsis, trauma, multiple organ failure	Acalculous cases	5 7 9
Hypersensitivity	Allergic or eosinophilic response	Eosinophilic variant	8 9

Table 3: Main Causes of Cholecystitis

Gallstones: The Usual Suspect

Gallstones are responsible for the majority of cholecystitis cases. They block the cystic duct, leading to bile accumulation, increased gallbladder pressure, and bacterial overgrowth 3 9 13.

Infections: The Bacterial Factor

Bacterial infection is present in about 50–85% of acute cholecystitis cases. The most commonly implicated organisms are Enterobacteriaceae such as E. coli, Klebsiella, and others. These bacteria can ascend from the gut and thrive in bile when stasis occurs. Rarely, unusual pathogens like Actinomyces species may be involved, especially in recurrent or persistent cases 10 12.

Ischemia and Systemic Illness

In acalculous cholecystitis, factors like shock, trauma, or severe illness reduce blood flow to the gallbladder, leading to tissue injury and inflammation 5 7 9. Critically ill or postoperative patients are especially at risk.

Medication and Bile Stasis

Certain drugs—such as oral contraceptives and those that impair gallbladder motility—can increase the risk of cholecystitis by altering bile composition or flow 9.

Hypersensitivity and Unusual Causes

Some cases, especially eosinophilic cholecystitis, may be driven by allergic or hypersensitivity reactions, possibly in response to altered bile or medications 8 9.

Treatment of Cholecystitis

Treating cholecystitis involves a combination of supportive care, medications, and sometimes surgery. The choice of therapy depends on the severity, type, and underlying health of the patient. Timely and appropriate management is key to preventing complications.

Approach	When Used	Details/Notes	Sources
Supportive care	All cases	Fluids, pain control, monitoring	15 17
Antibiotics	Most cases (esp. infectious)	Empirical, then targeted therapy	15 16 18
Surgery	Calculous/mild-moderate/severe	Laparoscopic cholecystectomy, timing varies	14 15 17
Drainage	Severe/critically ill	Percutaneous cholecystostomy	7 14 15
Conservative	Mild cases/high-risk patients	Non-surgical, may recur	17 18

Table 4: Main Treatment Approaches

Supportive Care: The Foundation

Initial management always includes supportive measures such as intravenous fluids, electrolyte correction, and pain control. Patients are monitored closely for any signs of deterioration 15 17.

Antibiotic Therapy

Empirical broad-spectrum antibiotics are started early, especially in moderate to severe cases or when infection is suspected 15 16. The choice is refined based on local resistance patterns and culture results. Newer guidelines recommend de-escalation and limiting antibiotic duration to reduce resistance 16 18.

Surgery: Laparoscopic Cholecystectomy

Surgical removal of the gallbladder (cholecystectomy) is the definitive treatment for most patients with calculous cholecystitis. Early laparoscopic cholecystectomy is favored for mild to moderate cases in suitable surgical candidates 14 15. For those with severe disease (Grade III), surgery is considered if the patient is stable and at experienced centers; otherwise, drainage is performed first 14.

Gallbladder Drainage

In critically ill patients or those who cannot undergo surgery immediately, percutaneous gallbladder drainage (cholecystostomy) is a life-saving alternative. It can stabilize patients before definitive surgery or serve as the sole therapy in some high-risk cases 7 14 15.

Conservative Management

For selected patients—especially those with mild disease or high surgical risk—non-operative management with antibiotics and supportive care can be effective. However, there is a risk of recurrence, with about 20% developing gallstone-related disease within a year of conservative treatment 17 18.

Special Considerations in Severe or Atypical Cases

• Acalculous cholecystitis often requires more aggressive intervention due to higher risks of gangrene and perforation 5 7.
• Emphysematous and hemorrhagic cholecystitis need prompt surgical or interventional therapy due to their high complication rates 6 11.
• Elderly and frail patients may need individualized treatment balancing risks and benefits 1 14.

Conclusion

Cholecystitis is a multifaceted disease with a spectrum of presentations, causes, and therapeutic options. Early recognition and tailored management are crucial for optimal outcomes.

Key Takeaways:

• Symptoms range from classic RUQ pain and fever to atypical signs, especially in older adults and critically ill patients 1 2.
• There are several types of cholecystitis, including calculous, acalculous, emphysematous, hemorrhagic, and eosinophilic variants 3 5 6 8 11.
• Causes include gallstones, infections, ischemia, medications, systemic illness, and hypersensitivity reactions 3 5 7 8 9 10 12.
• Treatment depends on severity and patient factors, combining supportive care, antibiotics, surgery, drainage, and sometimes conservative management 7 14 15 16 17 18.

Understanding the full spectrum of cholecystitis empowers patients and clinicians to make informed decisions and act swiftly when this gallbladder emergency strikes.