Diagnosis and Management of Elderly Patients with Right Upper Quadrant Pain and Gallstones

Diagnostic Considerations

The American College of Radiology notes that acute cholecystitis requires ≥2 ultrasound findings, including wall thickening, pericholecystic fluid, positive sonographic Murphy sign, gallbladder distension, or sludge/stones to establish the diagnosis 2
The absence of wall thickening does not completely exclude early acute cholecystitis, particularly in early presentations, but the negative sonographic Murphy sign further argues against acute inflammation 1
The clinical presentation of right upper quadrant pain with gallstones but without fever, leukocytosis, or inflammatory ultrasound findings is most consistent with biliary colic - episodic severe pain from gallstones causing transient cystic duct obstruction 2

The American College of Radiology recommends hepatobiliary scintigraphy (HIDA scan) as the next diagnostic step, with sensitivity of 97% and specificity of 90% for acute cholecystitis, if clinical suspicion for acute cholecystitis remains high despite the equivocal ultrasound findings 1
Alternative imaging options include CT abdomen with IV contrast, which can identify complications including gangrene, perforation, or adjacent liver parenchymal hyperemia, and MRI with MRCP and IV gadolinium contrast, which provides comprehensive evaluation and can distinguish acute from chronic cholecystitis based on T2 signal characteristics 3, 1
Early surgical consultation is warranted given the acute presentation with symptomatic gallstones in an elderly patient, and laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis, with the American College of Radiology recommending early cholecystectomy to reduce complications and hospital stay 1