Acute Cholecystitis

Clinical Picture

Steady and severe abdominal pain over the right upper quadrant radiating to the back, the right scapula, or the right clavicular area and associated with fever, nausea, anorexia, and vomiting is the main symptom of acute cholecystitis. Physical examination reveals tenderness over the gallbladder area. As the gallbladder area is palpated, the patient is asked to take a deep breath that brings the gallbladder down to the palpating hand. At the height of inspiration, as the gallbladder touches the palpating hand, the breath is arrested with a gasp (Murphy sign). The sign is not found in chronic cholecystitis. Sensitivity to Murphy sign may be diminished in elderly patients. Complications of acute cholecystitis are empyema of the gallbladder, gangrene with perforation, intraabdominal abscess, and diffuse peritonitis.

Laboratory findings include leukocytosis with a shift to the left and mildly elevated bilirubin and alkaline phosphatase levels. Serum amylase and lipase levels are normal or only mildly elevated unless there is concomitant acute pancreatitis. The differential diagnosis includes acute pancreatitis, appendicitis, acute hepatitis, peptic ulcer disease, disease of the right kidney, right-sided pneumonia, Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis), liver abscess, perforated viscus, and cardiac ischemia.