GPAtlas🧭 When to suspect
Acute cholecystitis is inflammation of the gallbladder, almost always caused by a gallstone impacting in the cystic duct (calculous cholecystitis). A minority – roughly 5–10% – are acalculous, occurring without stones in critically ill, ventilated or post–major-surgery patients, and carrying a higher complication rate. After biliary colic, it is the most common complication of gallstones.
Suspect it in sudden, severe, constant right upper quadrant (RUQ) pain lasting more than 6 hours, classically after a fatty meal and often radiating to the right shoulder or scapula, with fever, nausea and vomiting. A positive Murphy's sign (inspiratory arrest on deep RUQ palpation) is the classic clinical feature. Risk is summarised by the “5 Fs” – female, forty, fertile, fat, family history – though these are an aide-mémoire, not diagnostic criteria. The appearance of jaundice shifts your thinking towards a common bile duct (CBD) stone or ascending cholangitis.
The key primary-care skill is to place the presentation within the spectrum of gallstone disease – that is what decides whether the patient needs a routine referral, a same-day admission, or a blue-light emergency.
| Presentation | Distinguishing features | Primary-care action |
|---|---|---|
| Biliary colic | RUQ/epigastric pain lasting minutes to a few hours that settles; afebrile; normal inflammatory markers. | Analgesia; routine referral for elective cholecystectomy. |
| Acute cholecystitis | Constant RUQ pain > 6 hours, fever, positive Murphy's sign, raised WCC/CRP. | Same-day surgical admission. |
| Ascending cholangitis | Charcot's triad – RUQ pain + fever/rigors + jaundice (add hypotension + confusion = Reynolds' pentad). | Emergency admission – can deteriorate rapidly. |
| Gallstone pancreatitis | Severe epigastric pain radiating to the back, vomiting, systemically unwell; raised amylase/lipase. | Emergency admission. |
Source: NICE CG188 · NICE QS104
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