Radiology · Year 4 · from Radiology

Case 2: Acute Cholecystitis

Patient Demographics

  • Age: 48 years
  • Sex: Female

Chief Complaint

Severe right upper quadrant pain for 12 hours

Presenting Symptoms

The patient presents with sudden onset severe right upper quadrant pain that began after eating a fatty meal the previous evening. The pain is constant, radiates to the right shoulder, and is associated with nausea and multiple episodes of non-bilious vomiting. She reports similar but less severe episodes over the past year that resolved spontaneously. Risk factors include obesity, multiparity, and a family history of gallstones.

Physical Exam Findings

  • Vital Signs: BP 142/88 mmHg, HR 94 bpm, RR 18/min, Temp 38.1C
  • General: In obvious discomfort, unable to find comfortable position
  • Abdomen: Significant tenderness in right upper quadrant, positive Murphy sign (inspiratory arrest with palpation of the gallbladder), mild guarding, no rebound tenderness, no palpable mass
  • Laboratory: WBC 14,200/uL, Total bilirubin 1.8 mg/dL, ALT 62 U/L, AST 48 U/L, Lipase normal

Imaging Findings and Interpretation

Right Upper Quadrant Ultrasound:

  • Gallbladder: Distended with multiple mobile echogenic foci with posterior acoustic shadowing (gallstones)
  • Impacted Stone: Large stone (1.8 cm) lodged in the gallbladder neck
  • Wall Thickening: Gallbladder wall measures 5 mm (abnormal >3 mm)
  • Pericholecystic Fluid: Thin rim of anechoic fluid surrounding the gallbladder
  • Sonographic Murphy Sign: Positive - maximal tenderness elicited when transducer pressure applied directly over the gallbladder
  • Common Bile Duct: 4 mm in diameter (normal), no intraluminal stones visualized
  • Liver: Normal echogenicity, no intrahepatic biliary dilation

Diagnostic Criteria Met: The combination of gallstones, gallbladder wall thickening >3 mm, pericholecystic fluid, and positive sonographic Murphy sign meets diagnostic criteria for acute cholecystitis. The normal CBD and lack of intrahepatic ductal dilation make choledocholithiasis unlikely.

Diagnosis

Acute calculous cholecystitis with impacted stone in gallbladder neck

Management

  1. NPO status and IV fluid resuscitation
  2. IV antibiotics: Piperacillin-tazobactam (or ceftriaxone + metronidazole)
  3. Pain management with IV opioids and NSAIDs
  4. Surgical consultation for laparoscopic cholecystectomy
  5. Early cholecystectomy (within 72 hours) preferred if patient is a good surgical candidate
  6. If delayed surgery needed: Percutaneous cholecystostomy tube placement by interventional radiology
  7. Pathology: Acute cholecystitis confirmed on surgical specimen

Radiological Image

Image Description: Right upper quadrant ultrasound demonstrating acute cholecystitis with gallstones (echogenic foci with posterior acoustic shadowing), gallbladder wall thickening, and pericholecystic fluid. The sonographic Murphy sign is elicited by applying pressure with the transducer over the gallbladder.

Source: Wikimedia Commons - "Ultrasound showing gallstones" URL: https://commons.wikimedia.org/wiki/File:Gallstones_ultrasound.jpg License: Creative Commons Attribution-Share Alike 3.0 Unported

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