Acute Cholecystitis: The Inflamed Gallbladder and Why It Can Mean Urgent Surgery

Acute cholecystitis is a gallbladder that has become inflamed, and often infected, almost always because a gallstone has blocked its outlet, and unlike an ordinary attack the pain does not settle after a few hours and you feel genuinely unwell with it.¹ It is the reason a gallbladder problem that had been coming and going can suddenly turn into a hospital admission, and it is a large part of why doctors treat symptomatic gallstones rather than wait for the next attack.

My own attacks never crossed that line, but one of them scared me into thinking it had. The pain went on far longer than the others, I felt hot and wretched with it, and I ended up in an assessment unit convinced my gallbladder had turned septic. It had not, as it happened, and I was put on a planned list instead. But the difference between the attack I had and the one I feared is exactly what this page is about, and if you want the wider picture the whole operation is set out in gallbladder removal.

What is acute cholecystitis?

Acute cholecystitis is inflammation of the gallbladder, in most cases because a gallstone has become wedged in the narrow neck or the cystic duct, trapping bile inside the organ so that it swells, becomes irritated and frequently infected.¹ The gallbladder is the small pear-shaped organ under the liver that stores and concentrates bile, and gallstones are common: around 10 to 15% of adults in Western populations have them, more often women, with the rate rising with age².

Most of the time a stone that slips into the outlet drops back and the gallbladder empties again, which is a passing attack. When a stone stays stuck, the trapped bile turns the gallbladder into a hot, tender, sometimes pus-filled organ, and that is cholecystitis rather than simple colic³. Occasionally the gallbladder becomes inflamed without a stone at all, usually in people who are already seriously ill for another reason.

How it differs from an ordinary gallbladder attack

The distinguishing feature is that the pain does not go away: a normal gallbladder attack lasts minutes to a few hours and then fades, whereas cholecystitis is a constant, severe pain in the upper right abdomen that persists, usually with a fever and a general feeling of being unwell.¹ In a plain attack you are sore but otherwise fine between episodes; with cholecystitis you stay ill.

Biliary colic, the classic attack, is a gripping pain high under the right ribs, often an hour or two after a fatty meal, lasting minutes to a few hours³. Cholecystitis takes that same starting pain and lets it settle in, adding tenderness so sharp that pressing under the ribs can catch your breath, and often a temperature. The full range of what an attack feels like is set out in gallbladder attack symptoms. If you are ever unsure which one you are having, the honest answer is that a pain lasting many hours with a fever needs assessing in person, not talking yourself out of.

Why it often means urgent surgery

Acute cholecystitis usually leads to surgery because it marks a gallbladder that is actively causing trouble, and a symptomatic gallbladder carries roughly a 1 to 4% per year risk of a complication such as a blocked duct or further inflammation, which is why symptomatic stones are treated rather than watched.² Once your gallbladder has flared like this, it tends to flare again, and each attack carries that ongoing risk.

The definitive treatment is to remove the gallbladder, because with the organ gone the stones cannot form in it again⁴. Non-surgical options such as bile-acid tablets work slowly, suit very few people and often let stones return, so they do not solve the problem an acute attack has just demonstrated². NICE recommends laparoscopic cholecystectomy for people with symptomatic gallstones, and it names acute cholecystitis specifically as an indication for surgery⁵.

Early surgery versus waiting: the hot gallbladder

For acute cholecystitis, NICE recommends early laparoscopic cholecystectomy, often during the same hospital admission or within a week of diagnosis, rather than settling the attack and bringing you back weeks later.⁵ Operating while the tissues are freshly inflamed, before dense scarring sets in, is now the preferred approach for most people fit enough for it.

This is where the language of a “hot” gallbladder comes in: a gallbladder removed in the middle of an attack sits in swollen, stuck, bloody tissue that is harder to work around than a quiet, planned one. The stay reflects that too; where a booked keyhole removal is often a day case or a single overnight, an emergency operation for acute cholecystitis usually means a few days in hospital¹. The trade-offs between an unplanned admission and a booked list are set out in emergency versus planned gallbladder surgery.

When surgery has to wait: antibiotics and a drain

If you are not well enough for an immediate operation, the first attack is controlled with hospital admission, fluids, pain relief and antibiotics, and sometimes a small drain placed into the gallbladder to relieve it, with the gallbladder removed on a planned list once you have recovered.¹ This settles the current crisis without pretending to be a cure, because the stones are still there.

The drain, a cholecystostomy, is a thin tube passed through the skin into the inflamed gallbladder to let out the trapped, infected bile; it is used mainly for people who are too frail or too unwell for surgery at that moment. It buys time. Because the gallbladder and its stones remain, the attacks can recur, which is why removal is still usually advised later once things have calmed down².

The risks of operating on an inflamed gallbladder

Removing an acutely inflamed gallbladder is safe and routine but carries a higher risk than a planned operation on a quiet one, chiefly because the anatomy is harder to see: conversion from keyhole to open surgery is more likely, and the mortality of an emergency operation is higher than the very low figure (on the order of 0.1% or less) for a planned keyhole removal.⁴ Around 5 to 10% of keyhole operations overall are converted to open for safety, and that figure rises when the gallbladder is acutely inflamed, scarred, or the anatomy is unclear³.

The serious complication surgeons work hardest to avoid is bile duct injury, damage to the main bile duct reported at roughly 0.3 to 0.5% (about 1 in 200 to 1 in 300) with keyhole surgery⁴, and swollen, inflamed tissue makes the critical anatomy harder to identify, which is one reason a surgeon may deliberately convert to open or leave part of the gallbladder wall behind rather than push on. That single complication is worth understanding before you consent, and it is set out in full in bile duct injury. None of this is a reason to fear an operation that resolves a genuinely risky problem; it is a reason to have it done by a surgeon who does it often. The night I feared my own attack had tipped over, what steadied me was learning what the team would actually watch for, which I have written about in the attack that sent me to hospital.