Dr. Avinash Tank Invited Faculty at PUNJ SURG 2026

What is acute cholecystitis?

Acute cholecystitis is sudden inflammation of the gallbladder, the small pouch under the liver that stores bile. In most people it starts when a gallstone blocks the gallbladder's outlet (the cystic duct). Bile is trapped, the wall swells, and infection can follow.

It is one of the commonest reasons for emergency abdominal surgery. Many patients have had milder episodes of gallstone pain after fatty meals before an attack of cholecystitis.

What does "gallbladder perforation" mean?

If inflammation is severe or treatment is delayed, part of the gallbladder wall can lose its blood supply (gangrene) and break down. The result is a hole in the gallbladder, called perforation. It is an uncommon but serious complication.

• Bile and infection may stay walled off next to the gallbladder as an abscess. This is the most frequent pattern.
• Bile may leak freely into the abdomen and cause peritonitis, which is an emergency.
• Rarely, over time the gallbladder forms an abnormal channel into the bowel (a fistula).

Older age, diabetes, a weakened immune system and delay in seeking care increase the risk. Perforation makes surgery technically harder: tissues are swollen, fragile and stuck together, and the normal anatomy is distorted.

Symptoms and warning signs

Typical acute cholecystitis causes:

• Constant pain in the upper right or upper middle abdomen lasting more than a few hours, sometimes spreading to the right shoulder or back
• Fever, nausea and vomiting
• Tenderness under the right ribs, especially when breathing in
• Loss of appetite and feeling generally unwell

Seek urgent medical care for gallbladder pain with high fever or shivering, pain spreading across the whole abdomen, a rigid or very tender belly, yellow eyes (jaundice), confusion, or low blood pressure. These can mean perforation, spreading infection or a stone in the bile duct.

How it is diagnosed

An abdominal ultrasound is the first test. It shows the stones, a thickened gallbladder wall and fluid around the gallbladder. Blood tests (white cell count, CRP and liver function tests) show how much inflammation is present and whether the bile duct is affected.

When a complication such as perforation or an abscess is suspected, a CT scan maps the area. MRCP or endoscopic ultrasound is used if a stone in the main bile duct is suspected. Doctors also grade severity (mild, moderate or severe), which guides timing and type of treatment.

Treatment

Treatment begins in hospital with intravenous fluids, pain relief and antibiotics. For most patients who are fit for an operation, current guidance favours removing the gallbladder laparoscopically during the same admission, ideally early in the illness, rather than waiting weeks.

• Laparoscopic cholecystectomy: removal of the gallbladder through small incisions with a camera. It is the standard operation, including for many complicated cases in experienced hands.
• Drainage of any abscess or leaked bile, and sometimes a temporary drain after surgery.
• Percutaneous cholecystostomy: a tube placed through the skin to drain the gallbladder in patients too unwell for surgery. The gallbladder is removed later.
• ERCP when a stone is also blocking the main bile duct.

Occasionally a laparoscopic operation is converted to an open one, or the surgeon removes only part of the gallbladder. These are deliberate safety decisions when inflammation makes the anatomy unclear, not failures.

What "safe" laparoscopic cholecystectomy means

The most feared complication of gallbladder surgery is injury to the main bile duct. Inflamed or perforated gallbladders raise that risk because the tissues are swollen and the structures are hard to see. Surgeons use widely taught principles to keep the operation safe:

• Achieving the "critical view of safety": clearly identifying the only two structures entering the gallbladder before anything is cut
• Recognising when anatomy cannot be identified safely and changing plan rather than pressing on
• Using recognised "bail-out" options, such as subtotal cholecystectomy, or converting to open surgery, when needed
• Draining infection and leaving a drain where appropriate
• Operating in a centre with the imaging, endoscopy and intensive-care support that complicated cases may need

Teaching these techniques to fellow surgeons, often with operative video, is a regular part of surgical conferences.

Recovery

After an uncomplicated laparoscopic operation most people go home within one to two days. After cholecystitis with perforation, recovery is usually longer and depends on the degree of infection: antibiotics may continue for several days, a drain may stay in for a short time, and follow-up scans may be needed. People live normally without a gallbladder.