Cholecystitis, Acute

CHOLECYSTITIS, ACUTE 27A

A 52-year-old man presents to the emergency department with right upper quadrant (RUQ) abdominal pain for 8 hours. He states that it is steady and unrelenting and began about 1 hour after he ate a hamburger with French fries. Since the pain began, he has experienced episodic nausea and vomited once. On physical examination, he has a fever and marked tenderness to palpation over the RUQ of the abdomen with a positive Murphy sign on inspiration. The white blood cell (WBC) count is 19,000/mcL. Abdominal ultrasonography reveals a thickened gallbladder with multiple gallstones and pericholecystic fluid.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: RUQ abdominal pain; onset after a fatty meal; nausea and vomiting; fever and elevated WBC count; positive Murphy sign; thickened gallbladder and pericholecystic fluid on abdominal ultrasonography

How to think through: What causes of RUQ pain are important to consider in differential diagnosis? (Acute cholecystitis, acute pancreatitis, acute hepatitis, intraabdominal abscess, right lower lobe pneumonia, cardiac ischemia.) Could this be biliary colic? (The duration and unrelenting nature of the pain, along with the fever, indicate inflammation rather than the transient obstruction of biliary colic.) How would the presence of jaundice change your assessment? (Cholangitis, hepatitis, and hemolysis would rise in the differential diagnosis.) Is the ultrasound finding of gallstones sufficient to make the diagnosis of cholecystitis? (No. Cholelithiasis is common. The diagnosis of cholecystitis is a clinical one based on the history, examination, WBC, and ultrasound findings. Gallbladder wall edema on ultrasonography strongly suggests cholecystitis.) What are the initial steps in management? (Intravenous [IV] fluids, analgesia, surgical consultation.) Are antibiotics indicated? (Yes, given the fever and leukocytosis. About 40% of patients have positive biliary cultures, especially with Escherichia coli.) When should surgery be performed? (Immediate cholecystectomy generally improves outcomes. However, medical comorbidities or septic shock confer high surgical risk and may necessitate delay in surgery.) How are high-risk patients managed? (Often with antibiotics and percutaneous cholecystostomy with subsequent cholecystectomy.)