Anatomy Thorax Abdomen · Year 1 · from Anatomy Thorax Abdomen
Case 1: Acute Cholecystitis
Clinical Presentation
A 45-year-old obese female presents with severe right upper quadrant pain that began after a fatty meal 12 hours ago. The pain is constant, radiates to her right shoulder and infrascapular region, and is associated with nausea and vomiting. She has had similar but milder episodes in the past that resolved within a few hours. On examination, temperature is 38.5C, blood pressure is 140/90 mmHg, and heart rate is 100 beats per minute.
Abdominal examination reveals tenderness in the right upper quadrant with guarding. Murphy's sign is positive - the patient catches her breath when the examiner's fingers palpate deeply at the gallbladder point during inspiration. Laboratory studies show leukocytosis of 14,000/mm3 and mildly elevated liver enzymes. Right upper quadrant ultrasound demonstrates multiple gallstones with gallbladder wall thickening to 5 mm, pericholecystic fluid, and a positive sonographic Murphy's sign. She undergoes laparoscopic cholecystectomy the following day with identification of the critical view of safety within Calot's triangle.
Radiographic Findings
Image: Gallstones removed from the gallbladder. Calculous cholecystitis is caused by impaction of a stone in the cystic duct or gallbladder neck. Source: Wikimedia Commons, Public Domain.
Key Anatomical Points
- The gallbladder lies in the gallbladder fossa on the visceral surface of the liver between the right and quadrate lobes
- The cystic duct joins the common hepatic duct to form the common bile duct
- Calot's triangle is bounded by the cystic duct inferiorly, common hepatic duct medially, and liver superiorly
- The cystic artery typically arises from the right hepatic artery and crosses within Calot's triangle
Key Learning Points
- The "critical view of safety" requires visualization of only two structures (cystic duct and cystic artery) entering the gallbladder
- Murphy's sign indicates gallbladder inflammation when the inflamed organ contacts the examining hand during inspiration
- Referred pain to the right shoulder occurs via visceral afferents traveling with the greater splanchnic nerve to T7-T9
- Gallbladder pain may also be referred to the infrascapular region through the same dermatomal distribution