Gastrointestinal · Year 2 · from Gastrointestinal
Case 1: Acute Cholecystitis
Patient Presentation
Demographics: 45-year-old female
Chief Complaint: Right upper quadrant pain, fever, and nausea for 18 hours
History of Present Illness: The patient developed severe, constant right upper quadrant pain that started after eating a fatty meal last night. Unlike previous episodes of "gallbladder attacks" that resolved within hours, this pain has persisted and worsened. She has had fever, chills, and multiple episodes of nausea with vomiting. The pain radiates to her right shoulder.
Past Medical History: Known gallstones (diagnosed 2 years ago), obesity, two prior pregnancies
Social History: Non-smoker, occasional alcohol
Physical Examination
- Vital Signs: Temperature 38.6C, BP 128/82 mmHg, HR 102 bpm
- General: Uncomfortable female lying still, appears unwell
- Abdomen: Right upper quadrant tenderness with guarding; Murphy's sign positive (inspiratory arrest during RUQ palpation); no peritoneal signs; hypoactive bowel sounds
Workup and Results
- CBC: WBC 14,800 with 85% neutrophils
- Liver Function Tests: AST 52 U/L, ALT 68 U/L, ALP 145 U/L, Total bilirubin 1.4 mg/dL
- Lipase: Normal
- Right Upper Quadrant Ultrasound: Gallstones with posterior acoustic shadowing; gallbladder wall thickening (5 mm); pericholecystic fluid; positive sonographic Murphy sign
- HIDA Scan (confirmatory): Non-visualization of gallbladder at 4 hours (indicates cystic duct obstruction)
Ultrasound demonstrating acute cholecystitis with gallstones (echogenic focus with acoustic shadow), gallbladder wall thickening (>3mm), and pericholecystic fluid. The sonographic Murphy sign was positive.
Image Source: Case courtesy of Radiopaedia.org
Diagnosis
Acute Calculous Cholecystitis (Tokyo Grade II - Moderate)
Clinical Correlation
Acute cholecystitis develops when a gallstone impacts in the cystic duct and fails to dislodge, causing persistent gallbladder distension and inflammation. The pathophysiology progresses from obstruction to distension, wall ischemia, chemical inflammation, and secondary bacterial infection (50% of cases). This differs from biliary colic, which resolves within 6 hours when the stone dislodges. Murphy's sign is the hallmark physical finding - inspiratory arrest occurs as the inflamed gallbladder descends during inspiration and contacts the examining hand. Complications include gangrenous cholecystitis, perforation, and emphysematous cholecystitis. Tokyo Guidelines classify severity to guide management.
Treatment
- NPO, IV fluid resuscitation
- IV antibiotics: Piperacillin-tazobactam OR ceftriaxone + metronidazole
- Analgesia
- Early laparoscopic cholecystectomy (within 72 hours of symptom onset) - Grade II without organ dysfunction is amenable to early surgery
- If high surgical risk or organ dysfunction: percutaneous cholecystostomy followed by interval cholecystectomy
- Intraoperative cholangiogram to rule out CBD stones if indicated