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Introduction Fully covered self-expandable metal stents (FCSEMS) are widely used in the management of benign and malignant biliary obstruction and for the treatment of post-sphincterotomy bleeding. Obstruction of the cystic duct by FCSEMS may precipitate acute cholecystitis; however, the incidence of this complication is not well defined, with reported rates between 2.9% to 12%. 1 This audit aimed to evaluate the incidence of cholecystitis following FCSEMS insertion in a high-volume hepatopancreatobiliary centre.Methods A retrospective review was conducted of all patients who underwent FCSEMS insertion during ERCP between August 2022 and September 2025 at the Royal Free Hospital. Cases were identified using the electronic endoscopy reporting system (Medilogik), with clinical data obtained from the CERNER electronic patient record. Patients with prior cholecystectomy were excluded.Results A total of 161 patients met the inclusion criteria, including two with prior subtotal cholecystectomy. The median age was 73 years (range 20–91). Indications for FCSEMS placement included malignant biliary strictures (n=99), benign or indeterminate biliary strictures (n=45), post-sphincterotomy bleeding (n=14), bleeding from choledochal varices (n=2), and suspected duodenal perforation (n=1).Twelve patients (7.5%) developed both clinical and radiological features of acute cholecystitis following FCSEMS insertion, while two patients (1.2%) had clinical features without radiological confirmation. Three patients (1.9%) were found to have evidence of cholecystitis at subsequent surgery, and one patient (0.6%) demonstrated radiological features without clinical symptoms. Overall, 18 patients (11.2%) showed some evidence of cholecystitis; however, excluding the two patients without radiological confirmation and the asymptomatic patient with radiological findings, 15 patients (9.3%) were considered to have clinically relevant cholecystitis.Management included percutaneous cholecystostomy in two patients and attempted EUS-guided gallbladder drainage in one patient, which was not technically possible. One patient underwent repeat ERCP with exchange of FCSEMS for plastic stents. One patient with refractory cholecystitis did not undergo intervention due to frailty.Conclusions Despite the advantages of FCSEMS, including longer patency and reduced need for repeat procedures, this retrospective review demonstrates that cholecystitis is a relatively common complication in patients with an intact gallbladder. Patients should therefore be counselled and consented accordingly. While most cases were managed conservatively with antibiotics, a subset required further intervention.Reference Pausawasadi N, Soontornmanokul T, Rerknimitr R. Role of fully covered self-expandable metal stent for treatment of benign biliary strictures and bile leaks. Korean J Radiol. 2012;13:S67–73. doi: 10.3348/kjr.2012.13.S1.S67.