Reevaluating the Role and Timing of Fever in Acute Cholecystitis

Acute cholecystitis is diagnosed based on clinical and diagnostic findings. Fever is commonly considered a sign of systemic inflammation in acute cholecystitis, although its diagnostic performance may vary depending on the timing of presentation. This study analyzed the prevalence of fever as a diagnostic parameter for acute cholecystitis, according to the symptom onset at the time of medical consultation (≤ 24 hours versus > 24 hours), and its potential association with both medical and surgical complications.

We conducted a retrospective cohort study in two urban, tertiary care emergency departments (ED) between March 2023 and June 2024. Adult patients (≥ 18 years) with clinically diagnosed acute cholecystitis were included. Presentations were categorized by time since symptom onset: early (≤ 24 hours) or late (> 24 hours). Fever was defined as axillary temperature > 37.5 °C at home or at ED arrival. The primary outcome was the sensitivity of fever for the diagnosis of acute cholecystitis, stratified by early versus late presentation. Secondary outcomes included the sensitivity of other inflammatory markers and the association between fever and medical or surgical complications. The association between fever and complications was evaluated using a penalized logistic regression model (Firth method) to account for the low number of outcome events.

A total of 207 cases of acute cholecystitis were included in the analysis: 108 early presenters; and 99 late presenters. Fever was present in 4.6% (95% CI, 1.5-10.4) of early presenters and 20.2% (95% CI, 12.8-29.4) in late presenters, with an overall sensitivity of 12.1% (95% CI, 8.0-17.2). Medical and/or surgical complications were low in this cohort (n = 15, 7.2%), but more frequent in patients with fever, regardless of time onset of symptom (28% versus 4.5%, P < .001), yielding an adjusted odds ratio of 6.64 (95% CI, 1.42-31.21; P = .02) after adjusting for leukocyte count, C-reactive protein levels, and age.

Fever is an uncommon sign of acute cholecystitis, especially in early presentations, but may indicate a higher risk for complications when present. These findings underscore the need to reconsider the role of fever in current diagnostic criteria and suggest further validation of its use as a predictor of complications in prospective studies.