Cholecystitis

Cholecystitis is inflammation of the gallbladder, either acute or chronic, and can occur with (calculous) or without (acalculous) gallstones¹. The most common cause is a gallstone obstructing the outlet from the gallbladder (cystic duct), preventing bile from draining. This leads to painful distension and inflammation of the gallbladder wall, and the condition often requires prompt medical treatment.

The gallbladder is a small organ located beneath the liver on the right side of the upper abdomen. It stores bile—a dark green fluid produced in the liver that aids digestion².

Etiology

The most common cause of cholecystitis is gallstone obstruction of the cystic duct. When bile cannot drain, pressure builds up, resulting in inflammation of the gallbladder wall and a risk of infection. However, other causes exist. Tumors compressing the bile ducts, reduced blood supply to the gallbladder, and various infections can lead to the same type of inflammation even without stones. In critically ill patients or after major trauma, acalculous cholecystitis may develop—meaning inflammation without gallstones.

Risk factors include obesity, rapid weight loss, fasting, diabetes, and blood disorders causing increased red blood cell breakdown (e.g., sickle cell anemia, which raises the risk of pigment stones).).

Epidemiology

Gallstones are very common in the population, with approximately 10–20% affected during their lifetime. Of these, up to 80% will never develop symptoms. The prevalence of gallstones and gallstone-related disease increases significantly with age, and women over 60 are particularly at risk. Other factors that raise risk include obesity, rapid weight loss, fasting, and chronic conditions such as diabetes.

In the United States, an estimated 500,000 gallbladder removals (cholecystectomies) are performed annually. Conditions that increase red blood cell breakdown, such as sickle cell anemia, more frequently lead to pigment stones, which can also cause cholecystitis⁴.

Pathology

Over 90% of chronic cases are directly related to gallstones, which repeatedly and partially block the cystic duct, causing recurrent inflammation. Over time, the inflammation thickens and stiffens the gallbladder wall, increasing the risk of scarring and, in some cases, tissue necrosis or rupture. In acute, untreated cases, the condition can progress to perforation, severe infection (sepsis), and death.

Symptoms and Clinical Presentation

The most prominent symptom of cholecystitis is intense, persistent pain localized to the upper right abdomen—often radiating to the right shoulder or between the shoulder blades. The pain typically occurs after large, fatty meals and is often accompanied by nausea, vomiting, fever, and general malaise. Many also experience indigestion and worsening symptoms after fatty foods. In some cases, symptoms may be vague, particularly in elderly patients, with fever or tenderness as the only findings.

Diagnosis

Diagnosis is primarily based on patient history and clinical examination, but abdominal ultrasound is the most important imaging tool to confirm gallstones and assess gallbladder inflammation. Blood tests may show elevated infection markers or liver involvement, though such findings are often absent in chronic cholecystitis. Other supplementary tests may include metabolic panel, liver function tests, and complete blood count. In cases of atypical abdominal pain, ECG and troponins may be performed to rule out heart disease³.

Treatment

In acute cholecystitis, patients are usually admitted for monitoring, fasting, intravenous fluids, antibiotics, and pain relief. A low-fat diet may relieve symptoms, and in some cases, medical dissolution of stones may be attempted. The definitive treatment is usually surgery, in which the gallbladder is removed—most often laparoscopically, typically within 2–3 days of admission. This allows faster rehabilitation and shorter hospital stay. After surgery, bile flows directly from the liver to the intestines, and a gallbladder is not required for normal digestion. Multidisciplinary follow-up and dietary counseling are particularly important for patients who are not immediately operated on³.

Complications

If untreated, the condition may lead to severe complications such as hepatitis, gallbladder rupture, severe infection (sepsis), or tissue necrosis. In rare cases, chronic inflammation may increase the long-term risk of gallbladder cancer. Untreated cholecystitis can therefore be life-threatening.

Physiotherapy in Cholecystitis

Physiotherapists should always be aware that pain in the mid-back, scapular region, or right shoulder without trauma may be caused by gallbladder or liver disease. It is particularly important to screen for systemic disease if the patient has unclear or widespread pain, pain not following a typical musculoskeletal pattern, or accompanying gastrointestinal symptoms—especially after meals. Patients with known gallbladder disease, liver involvement, hepatitis, or recent surgery should be evaluated carefully.

Warning signs and referral:

• Newly developed muscle weakness, especially in the elderly or in patients using statins, requires immediate medical evaluation

• Previous or current cancer, risk factors for hepatitis, bilateral carpal tunnel syndrome, or unexplained neuropathy with liver symptoms indicate referral to a physician

• Jaundice, alcohol overuse, intravenous drug use, recent surgery, or contact with others with jaundice are risk factors for hepatitis and liver disease that must be evaluated

Postoperative physiotherapy:

• Patients should be encouraged to begin early mobilization and gradually increase activity as soon as medically safe, to promote bowel function and reduce postoperative complications

• Key early postoperative measures include:

  • Breathing exercises to prevent pneumonia and improve oxygenation

  • Position changes and varied lying positions to prevent pressure sores and promote circulation

  • Coughing and wound-splinting techniques to protect the surgical site and prevent respiratory problems

  • Compression stockings to prevent venous thrombosis

  • Simple lower extremity exercises to stimulate circulation and reduce risk of thrombosis

• The physiotherapist should also assess pain and range of motion, advise on activity progression, and adapt exercises based on health status and potential complications

Prognosis

Both acute and chronic cholecystitis have a good prognosis when patients receive appropriate medical treatment and surgery if indicated. Elevated white blood cells, CRP, and procalcitonin levels indicate severity and risk of complications. Gangrene, abscess, advanced age (>60 years), or serious comorbidities increase the risk of postoperative complications and mortality (5–10% in high-risk patients). The condition may recur if the gallbladder is not removed.

Differential Diagnoses

Cholecystitis may present with symptoms overlapping several other acute conditions of the upper abdomen. Important differential diagnoses include:

• Acute appendicitis

• Gallstone attack (biliary colic)

• Cholangitis (inflammation of the bile ducts)

• Mesenteric ischemia (reduced blood supply to the intestines)

• Gastritis

• Peptic ulcer (gastric or duodenal ulcer)⁴

Sources

1. Howard, M. (2015). Medisinsk ernæringsterapi ved kolecystitt, kolelitiasis og kolecystektomi.

2. Health Direct. (u.å.). Kolecystitt. Tilgjengelig fra https://www.healthdirect.gov.au/cholecystitis-gallbladder-inflammation

3. Jones, M. W., Gnanapandithan, K., Panneerselvam, D., & Ferguson, T. (u.å.). Kronisk kolecystitt. Tilgjengelig fra https://www.ncbi.nlm.nih.gov/books/NBK470236/

4. Jones, M. W., Genova, R., & O’Rourke, M. C. (u.å.). Akutt kolecystitt. Tilgjengelig fra https://www.ncbi.nlm.nih.gov/books/NBK459171/

5. Goodman, C. C., & Snyder, T. E. K. (2013). Differensialdiagnostikk for fysioterapeuter – screening for henvisning. St. Louis, MO: Saunders Elsevier.

6. Goodman, C. C., & Boissonnault, W. (1998). Patologi – implikasjoner for fysioterapeuter. Philadelphia: Saunders.

7. Goodman, C. C., & Fuller, K. (2009). Patologi – implikasjoner for fysioterapeuter (3. utg.). St. Louis: Saunders Elsevier.

8. Yuzbasioglu, Y., Duymaz, H., Tanrikulu, C., Halhalli, H., Koc, M., Coskun, F., mfl. (2016). Rollen til prokalsitonin i vurdering av alvorlighetsgrad ved akutt kolecystitt. Eurasian Journal of Medicine, 48(3), 162–166.

9. Terho, P., Leppäniemi, A., & Mentula, P. (2016). Laparoskopisk kolecystektomi ved akutt kalkuløs kolecystitt: En retrospektiv studie av risikofaktorer for konvertering og komplikasjoner. World Journal of Emergency Surgery, 11, 1–9.

10. Asiltürk Lülleci, Z., Başyiğit, S., Pirinççi Sapmaz, F., Uzman, M., Kefeli, A., Nazlıgül, Y., mfl. (2016). Sammenligning av ultralyd- og laboratoriefunn ved akutt kolecystitt mellom eldre og yngre pasienter. Turkish Journal of Medical Sciences, 46(5), 1428–1433.