Diagnosis and Management of Acute Cholecystitis

Clinical Presentation and Diagnosis

The American College of Radiology recommends obtaining a right upper quadrant ultrasound to confirm the diagnosis and assess for gallstones, gallbladder wall thickening, pericholecystic fluid, and other inflammatory findings in patients with suspected acute cholecystitis 1, 2
A positive Murphy's sign on physical examination is the most specific clinical finding, with a positive likelihood ratio of 2.8, though it has relatively low specificity 1, 3
Right upper quadrant pain that is continuous, sharp, and aggravated by inhalation and eating is characteristic of gallbladder inflammation 3, 2
Obesity (BMI 34.9) is a significant risk factor for gallstone disease, which underlies 95% of acute cholecystitis cases 4
The World Journal of Emergency Surgery suggests that the lack of documented fever or elevated white blood cell count does not exclude acute cholecystitis, as no single clinical or laboratory finding has sufficient diagnostic power to establish or exclude the diagnosis 3

Ultrasound is the mandatory first-line imaging test and should be performed immediately, with a sensitivity of 88% and specificity of 80% for acute cholecystitis 1
The Journal of the American College of Radiology recommends looking for the following ultrasound findings: gallstones or sludge, gallbladder wall thickening (>3mm), pericholecystic fluid, gallbladder distension, sonographic Murphy's sign, and stones impacted in the gallbladder neck or cystic duct 1, 5, 6
At least 2 ultrasound findings are required to establish the diagnosis of acute cholecystitis 5
If ultrasound is equivocal or negative, hepatobiliary scintigraphy (HIDA scan) is the preferred next test, with a sensitivity of 97% and specificity of 90% for acute cholecystitis 1, 5

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment for acute cholecystitis, reducing complications and hospital stay 2, 5
Antibiotic therapy should be initiated, with amoxicillin/clavulanate, eravacycline, or tigecycline for 2-4 days if source control is adequate 2
Immediate surgical consultation is warranted given the acute presentation with symptomatic gallstones 5

RUQ or epigastric pain is the most common presenting symptom, reported in 72 %–93 % of patients with acute cholecystitis. 9
Fever is present in only 36 %–74 % of cases, and a temperature > 38 °C occurs in merely 6.4 %–10 % of patients. 9
Vomiting or food intolerance occurs in 38 %–48 % of affected individuals. [9][10]
Abdominal tenderness or guarding is observed in approximately 65 % of patients. 9
Murphy’s sign has a positive likelihood ratio of 2.8 but low sensitivity (43 %–48 %); its absence does not rule out disease. 9
In elderly patients, atypical or absent pain is seen in 12 %–17 % of cases, and a positive Murphy’s sign is present in only 43 % of this subgroup. 9

Leukocytosis is documented in 41 %–59 % of acute cholecystitis episodes. 9
C‑reactive protein levels > 75 mg/L strongly support the diagnosis. 10
Elderly patients tend to exhibit higher rates of leukocytosis and elevated CRP compared with younger cohorts, enhancing the diagnostic value of these markers in that population. 9

Pericholecystic fluid on right‑upper‑quadrant ultrasound is a recognized sonographic feature of acute cholecystitis. 10

No single clinical, laboratory, or imaging finding is sufficient to confirm or exclude acute cholecystitis; a multimodal approach is required. 10
The most reliable diagnostic method combines detailed history, physical examination, laboratory testing, and imaging—specifically, ultrasound demonstrating at least two characteristic findings (e.g., gallstones, wall thickening, pericholecystic fluid). 10

For any patient with suspected acute cholecystitis, obtain a thorough history focusing on RUQ/epigastric pain, fever, vomiting, and food intolerance; perform a physical exam assessing Murphy’s sign and tenderness; order CBC with differential and CRP; and acquire an immediate right‑upper‑quadrant ultrasound looking for ≥ 2 diagnostic sonographic signs. This integrated algorithm yields the highest diagnostic accuracy. 10