General Surgery · Year 3 · from General Surgery

Case 1: Acute Cholecystitis

Patient Demographics

  • Age: 45 years
  • Sex: Female
  • Occupation: School administrator

Chief Complaint

"I have severe pain under my right ribs that started after dinner last night."

History of Present Illness

The patient presents with an 18-hour history of constant, severe right upper quadrant pain. The pain began after eating a fatty meal and has been progressively worsening. She reports nausea with two episodes of non-bilious vomiting. She has had prior episodes of milder, similar pain that resolved spontaneously (biliary colic), but this episode is more severe and persistent. She reports subjective fever and chills.

Past Medical History

  • Obesity (BMI 32)
  • History of biliary colic (diagnosed on ultrasound 2 years ago, declined surgery)
  • Hyperlipidemia

Medications

  • Atorvastatin 20 mg daily

Risk Factors

Classic "4 F's": Female, Forty, Fat, Fertile

Physical Examination

  • Vitals: BP 142/88 mmHg, HR 98 bpm, Temp 38.4°C, RR 18/min
  • General: Overweight female in moderate distress
  • Abdomen:
  • RUQ tenderness with guarding
  • Positive Murphy's sign (inspiratory arrest during RUQ palpation)
  • No rebound tenderness
  • No palpable mass
  • Bowel sounds present

Laboratory Results

  • WBC: 14,600/μL (left shift)
  • Total bilirubin: 1.4 mg/dL (mildly elevated)
  • ALT: 68 U/L (mildly elevated)
  • AST: 54 U/L
  • Alkaline phosphatase: 142 U/L (mildly elevated)
  • Lipase: 45 U/L (normal)

Imaging

Right Upper Quadrant Ultrasound:

  • Gallstones present (multiple)
  • Gallbladder wall thickening (5 mm)
  • Pericholecystic fluid
  • Sonographic Murphy's sign positive
  • Common bile duct: 4 mm (normal)
  • No intrahepatic ductal dilation

Diagnosis

Acute calculous cholecystitis

Initial Management

  1. NPO
  2. IV fluid resuscitation
  3. IV antibiotics (ceftriaxone + metronidazole)
  4. Pain control (IV ketorolac, opioids)
  5. Surgical consultation for cholecystectomy

Timing of Surgery

  • Tokyo Guidelines Grade II (moderate) cholecystitis
  • Patient is surgical candidate
  • Plan: Early laparoscopic cholecystectomy (within 72 hours preferred)

Operative Procedure

Laparoscopic cholecystectomy:

  • Omental adhesions to gallbladder
  • Gallbladder distended, inflamed, wall edematous
  • Achieved critical view of safety (CVS)
  • Cystic duct and cystic artery clearly identified and clipped
  • Gallbladder removed in retrieval bag
  • Subhepatic drain NOT placed (routine drainage not recommended)

Intraoperative Cholangiogram

  • Not performed (preoperative labs and imaging did not suggest CBD stones)
  • Alternative: Could have performed if concern for choledocholithiasis

Pathology

  • Acute cholecystitis with cholelithiasis
  • Multiple cholesterol stones
  • No evidence of malignancy

Postoperative Course

  • Diet advanced evening of surgery
  • Pain well controlled with oral analgesics
  • Discharged POD 1

Follow-up

  • Wound check at 1 week: Healing well
  • Full activity resumed at 2 weeks

Teaching Points

  1. Positive Murphy's sign is specific for acute cholecystitis
  2. Ultrasound is first-line imaging
  3. Early cholecystectomy (<72 hours) is preferred when feasible
  4. Critical view of safety (CVS) prevents bile duct injury
  5. Mild liver enzyme elevation can occur with cholecystitis (reactive hepatitis)
  6. CBD stones should be considered if bilirubin elevated or CBD dilated

Clinical Image

Image Description: Right upper quadrant ultrasound demonstrating gallstones with posterior acoustic shadowing, gallbladder wall thickening (>4 mm), and pericholecystic fluid consistent with acute cholecystitis.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Gallstones

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