Acute cholecystitis is a sudden inflammation of the gallbladder, most often triggered when a gallstone gets stuck in the duct that drains bile out of it. The blockage traps bile inside, pressure builds, and the gallbladder wall becomes swollen, irritated, and sometimes infected. It’s one of the most common reasons for emergency abdominal surgery, and roughly 25% to 30% of patients develop complications or need urgent intervention.
How Gallbladder Inflammation Develops
Your gallbladder is a small, pear-shaped organ tucked under your liver. Its job is to store bile, a digestive fluid your liver produces, and release it into the small intestine when you eat. Bile leaves the gallbladder through a narrow tube called the cystic duct. When a gallstone lodges in that duct, bile has no way out.
Trapped bile causes pressure inside the gallbladder to rise. That mounting pressure squeezes the blood vessels in the gallbladder wall, reducing blood flow. With less oxygen reaching the tissue, the wall becomes inflamed and begins to swell. At the same time, stagnant bile creates a breeding ground for bacteria, which intensifies the inflammation further. If nothing is done to relieve the pressure, the tissue can lose blood supply entirely and begin to die, a condition called gangrenous cholecystitis, which can progress to perforation (a hole in the gallbladder wall).
Cholecystitis Without Gallstones
About 5% to 10% of cases happen without any gallstones at all. This form, called acalculous cholecystitis, tends to affect critically ill patients: people in intensive care recovering from major surgery, heart attacks, strokes, severe burns, or sepsis. The underlying problem is the same (bile stagnation, rising pressure, reduced blood flow) but the trigger is different. Prolonged fasting, IV nutrition that bypasses the gut, rapid weight loss, or simply being too sick for the gallbladder to contract normally can all set it off. People living with HIV or other conditions that suppress the immune system also face higher risk.
Acalculous cholecystitis is particularly dangerous because it tends to progress to gangrene and perforation faster than the gallstone-related version, making early recognition critical.
What It Feels Like
The hallmark symptom is a steady, intense pain in the upper right side of your abdomen, just below your ribs. Unlike the cramping pain of a gallstone attack that comes in waves and passes within a few hours, the pain of acute cholecystitis persists, often lasting well beyond six hours and worsening over time. It may radiate to your right shoulder or back.
Fever is common, and many people experience nausea or vomiting. Some develop a faint yellowish tint to the skin or eyes, though this is often subtle enough to miss. Eating, especially fatty food, tends to make the pain worse because your body signals the gallbladder to contract, increasing pressure against the blockage.
During a physical exam, pressing on the right side of the abdomen while you take a deep breath typically causes a sharp spike in pain. This response, known as Murphy’s sign, happens because your inflamed gallbladder drops down as you inhale and makes contact with the examiner’s hand. A positive Murphy’s sign is one of the most reliable bedside clues pointing toward acute cholecystitis.
How It’s Diagnosed
Diagnosis usually starts with blood work and imaging. Blood tests often show elevated white blood cell counts, a sign the body is fighting inflammation or infection. Liver-related markers frequently climb as well. In confirmed cases, bilirubin (a waste product processed by the liver) is abnormal nearly half the time, and liver enzymes are elevated in more than half of patients. These lab results help doctors gauge severity but don’t confirm the diagnosis on their own.
Ultrasound is the first imaging test ordered because it’s fast, widely available, and good at spotting gallstones, thickened gallbladder walls, and surrounding fluid. However, ultrasound has a relatively modest sensitivity for confirming the inflammation itself, picking up only about 26% of true cases in some analyses while being fairly good at ruling out other conditions.
When ultrasound results are inconclusive, a specialized nuclear medicine scan (often called a HIDA scan) provides a clearer answer. This test tracks a small amount of radioactive tracer as it moves through the bile system. If the tracer fills the liver’s bile ducts but never enters the gallbladder, it confirms that the cystic duct is blocked. The HIDA scan has a sensitivity around 87%, making it significantly more accurate for catching cases that ultrasound might miss.
Treatment and Surgical Timing
The definitive treatment is cholecystectomy, surgical removal of the gallbladder. Current guidelines strongly favor performing surgery within 72 hours of hospital admission. Studies consistently show that this early approach reduces complications, shortens hospital stays, and lowers overall costs compared to sending a patient home and scheduling surgery weeks later.
Most cholecystectomies are done laparoscopically, through a few small incisions in the abdomen using a camera and thin instruments. Recovery from laparoscopic surgery is relatively quick: most people go home within a day or two and return to normal activities within one to two weeks. However, if the surgeon encounters significant infection or tissue damage (such as empyema, where the gallbladder fills with pus), the procedure may need to be converted to a larger, open incision, which means a longer recovery.
For patients who are too sick to tolerate surgery, a less invasive option exists. A thin drainage tube can be placed through the skin and into the gallbladder, guided by imaging, to relieve pressure and drain infected bile. This approach is typically reserved for critically ill patients or those with severe underlying health problems that make general anesthesia risky. It stabilizes the situation but doesn’t eliminate the underlying problem, so surgery is usually planned once the patient is strong enough.
Complications to Watch For
When treatment is delayed or the disease progresses rapidly, several serious complications can develop. Gangrenous cholecystitis occurs when the gallbladder wall loses its blood supply and tissue begins to die. This raises the risk of perforation, which can spill infected bile into the abdominal cavity and cause peritonitis, a life-threatening infection of the abdominal lining.
Empyema, the accumulation of pus inside the gallbladder, is another complication that signals worsening infection. Patients with empyema often look and feel significantly sicker, with higher fevers and more dramatic rises in white blood cell counts. Surgery in these cases is more complex and more likely to require an open approach.
The speed at which complications develop varies. Gallstone-related cases sometimes simmer for days before worsening, giving a clear window for surgery. Acalculous cases, by contrast, can deteriorate rapidly, which is why they carry higher mortality rates despite affecting a smaller number of patients.
Life After Gallbladder Removal
Living without a gallbladder is entirely manageable. Bile still flows from the liver directly into the small intestine; you simply lose the storage reservoir that concentrated and released it on demand. Most people notice no long-term dietary limitations. Some experience looser stools or mild digestive discomfort in the weeks following surgery, particularly after fatty meals, but this typically resolves as the body adjusts. A small percentage of people have more persistent changes in bowel habits, but serious long-term consequences are rare.