Anatomy Thorax Abdomen · Year 1 · from Anatomy Thorax Abdomen
Case 2: Acute Cholecystitis
Patient Demographics
- Age: 45 years old
- Sex: Female
- Occupation: Administrative assistant
Chief Complaint
Severe right upper quadrant pain for 8 hours.
History of Present Illness
The patient describes the acute onset of constant, severe pain in the right upper quadrant after eating a fatty meal last evening. The pain radiates to her right shoulder and is associated with nausea and two episodes of non-bilious vomiting. She reports having had similar but milder episodes of right upper quadrant discomfort after fatty meals for the past year that would resolve within an hour. This episode is different in that the pain has been constant and more severe. She denies jaundice, dark urine, or light-colored stools.
Physical Examination
- Vitals: HR 92 bpm, BP 138/84 mmHg, RR 16, Temp 38.1C, SpO2 99% on room air
- General: Appears uncomfortable, lying still
- Abdomen: Soft, positive Murphy sign (arrest of inspiration during palpation of the right upper quadrant), no rebound tenderness, bowel sounds present
- Skin: No jaundice or icterus
Imaging Workup
- Right upper quadrant ultrasound (first-line for suspected biliary disease):
- Multiple echogenic foci in the gallbladder with posterior acoustic shadowing (gallstones)
- Gallbladder wall thickening to 5 mm (normal <3 mm)
- Pericholecystic fluid present
- Positive sonographic Murphy sign
- Common bile duct measures 4 mm (normal <6 mm)
- Laboratory studies: WBC 14,500/microL with left shift, AST 42 U/L, ALT 48 U/L, alkaline phosphatase 110 U/L, total bilirubin 1.1 mg/dL
Diagnosis
Acute calculous cholecystitis with characteristic ultrasound findings.
Anatomical Correlation
Ultrasound is the first-line imaging modality for suspected biliary disease because it has excellent sensitivity for detecting gallstones and does not involve ionizing radiation. Gallstones appear as echogenic (bright) foci with posterior acoustic shadowing because they absorb and reflect the ultrasound beam, preventing transmission to deeper tissues. The normal gallbladder wall measures less than 3 mm in thickness; wall thickening indicates inflammation. Pericholecystic fluid represents inflammatory exudate surrounding the gallbladder. The sonographic Murphy sign is pain elicited when the ultrasound transducer presses the gallbladder against the liver during inspiration. The referred pain to the right shoulder follows the T7-T9 dermatomes, corresponding to the sensory innervation of the gallbladder via the greater splanchnic nerve.
Treatment
- NPO status and IV fluids
- Analgesia and antiemetic medications
- IV antibiotics: Coverage for enteric gram-negative organisms and anaerobes
- Laparoscopic cholecystectomy: Definitive treatment, preferably within 72 hours of symptom onset