Gastroenterology · Hepatobiliary
The facts most likely to be tested
The most common cause of acute cholecystitis is gallstone impaction in the cystic duct leading to gallbladder inflammation.
The classic clinical presentation is right upper quadrant (RUQ) pain or epigastric pain that is constant and often radiates to the right scapula.
Murphy sign, defined as the cessation of inspiration during deep palpation of the RUQ, is the most specific physical exam finding.
Right upper quadrant ultrasound is the initial diagnostic test of choice and typically reveals gallstones, gallbladder wall thickening (>3 mm), and pericholecystic fluid.
HIDA scan (cholescintigraphy) is the gold standard diagnostic test when ultrasound findings are equivocal or inconclusive.
Initial management includes bowel rest (NPO), intravenous fluids, analgesia, and broad-spectrum intravenous antibiotics.
Laparoscopic cholecystectomy is the definitive treatment and should be performed early (ideally within 24–72 hours of admission) to reduce morbidity.
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A 45-year-old female presents to the emergency department with a 12-hour history of constant, severe right upper quadrant pain radiating to her right shoulder. She reports a similar, though milder, episode after eating a fatty meal last month. Physical examination reveals a febrile patient with tenderness in the right upper quadrant and a positive Murphy sign. Laboratory studies show a leukocytosis with a left shift, while liver function tests are within normal limits.
What is the most appropriate next step in the management of this patient?
Right upper quadrant ultrasound
The patient presents with classic signs of acute cholecystitis; the initial diagnostic test of choice is a RUQ ultrasound to confirm the presence of gallstones and gallbladder wall inflammation.
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Etiology / Epidemiology
Caused by cystic duct obstruction from gallstones in 95% of cases. Risk factors: Female, Forty, Fat, Fertile (4 Fs).
Clinical Manifestations
RUQ pain, fever, and leukocytosis. Murphy's sign is the pathognomonic physical exam finding.
Diagnosis
HIDA scan is the gold standard; RUQ ultrasound is the initial diagnostic test of choice.
Treatment
Cholecystectomy is definitive. Manage with IV fluids, bowel rest, and ceftriaxone + metronidazole.
Prognosis
Most recover with surgery. Gangrenous cholecystitis and perforation are life-threatening complications.
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Epidemiology & Etiology
Predominantly affects patients with cholelithiasis. Incidence increases with age and metabolic syndrome. Obstruction leads to inflammation, ischemia, and secondary bacterial infection.
Pertinent Anatomy
The gallbladder stores bile; the cystic duct connects it to the common bile duct. Obstruction at the cystic duct prevents bile outflow, causing gallbladder distention and wall inflammation.
Pathophysiology
Stasis of bile promotes stone formation. Persistent obstruction causes increased intraluminal pressure, leading to mucosal ischemia and chemical inflammation. Secondary bacterial overgrowth (e.g., E. coli) often follows.
Clinical Manifestations
Patients present with steady, severe RUQ or epigastric pain, often radiating to the right scapula (Boas sign). Murphy's sign (inspiratory arrest on deep palpation) is highly sensitive. Fever, tachycardia, and jaundice suggest complications like cholangitis or choledocholithiasis.
Diagnosis
RUQ ultrasound is the first-line test, showing gallbladder wall thickening >3mm, pericholecystic fluid, and sonographic Murphy's sign. The HIDA scan is the gold standard for diagnosis if ultrasound is equivocal, demonstrating non-visualization of the gallbladder.
Treatment
Initial management includes IV fluids, analgesia, and IV antibiotics (e.g., ceftriaxone + metronidazole). Early laparoscopic cholecystectomy is the definitive treatment. Avoid opioids like morphine if possible due to theoretical sphincter of Oddi spasm, though clinical evidence is debated.
Prognosis
Early surgical intervention prevents gangrenous cholecystitis and gallbladder perforation. Monitor for sepsis and abscess formation in elderly or diabetic patients.
Differential Diagnosis
Choledocholithiasis: presence of stones in the common bile duct causing jaundice
Ascending Cholangitis: presents with Charcot's triad (fever, RUQ pain, jaundice)
Biliary Colic: pain is transient and lasts <6 hours without inflammation
Peptic Ulcer Disease: epigastric pain relieved by food or antacids
Acute Pancreatitis: elevated lipase and epigastric pain radiating to the back