In presentation of acute abdomen, duodenal perforation is fast being replaced by acute biliary and pancreatic disease and these are now the second commonest cause of acute inflammatory intra-abdominal condition after acute appendicitis. Acute cholecystitis is a fairly common abdominal emergency. Patient presents with severe abdominal pain in the right upper quadrant, pain on deep inspiration and occasionally with vomiting or jaundice. Abdominal x-ray PA and right lateral rarely may show radio-opaque calculus lying in the right upper quadrant anterior to the vertebral body. X-ray chest and x-ray abdomen in standing helps to rule out peptic perforation and intestinal obstruction. Ultrasound is very helpful. It shows thickened gall bladder wall, distended gall bladder with presence of gallstones. It also shows peri-cholecystitis, fluid and sonographic Murphy’s sign is positive. ERCP is necessary when pain is associated with jaundice and non-dilated intrahepatic bile ducts. Rarely Mirrizzi’s syndrome-a stone impacted in cholecysto-choledocal fistula may be found. Medical management followed by surgery after 6 to 8 weeks used to be the standard treatment. But considering mortality, morbidity and cost: early cholecytectomy after initial treatment and investigation is preferred. The operation should be done in first three days. Mortality of early surgery is now less than 0.5 percent. Open cholecystectomy or laparoscopic cholecystectomy should be decided by the operating surgeon and should depend on the surgeons training, capacity and preference. If calculii load is not heavy, and empyema, pyocoele or peritonitis is not expected, laparoscopic cholecystectomy is preferred. Clinical features of AAC differ from calculus cholecystitis. Although right upper quadrant pain, fever, localized tenderness over right 10th rib tip and leucocytosis may be present but rarely some or all the features may be absent. Often the only finding may be fever of unexplained origin and hyper-amylasemia and other symptoms and signs of cholecystitis may appear rarely later on. The clinical course is more fulminant; by the time of diagnosis about half have already developed some complications of cholecystitis like gangrene or localized perforation. Supportive medical care should include restoration of haemodynamic stability and proper antibiotic coverage for gram negative enteric flora and anaerobes. Given the rapid progression of AAC to empyema, gangrene or perforation, early recognition and intervention is a must. In a patient who is not stable; sonographically guided, percutaneous transhepatic cholecystostomy be done as an initial treatment, followed by cholecystectomy after few days.
