Acute Cholecystitis Diagnosis and Management

Clinical Presentation and Diagnosis

The American College of Radiology notes that a distended gallbladder with multiple gallstones in the setting of acute right upper quadrant (RUQ) pain and vomiting is highly suggestive of cystic duct obstruction, the primary pathogenic mechanism of acute cholecystitis 1.
The absence of wall thickening does not exclude acute cholecystitis, particularly in early presentations, according to the ACR guidelines 2.
Empyema represents a complication of acute cholecystitis with purulent material in the gallbladder, typically presenting with more severe systemic signs including fever and marked leukocytosis, which are absent in this patient 2.
The American College of Radiology recommends hepatobiliary scintigraphy (HIDA scan) if clinical suspicion remains high despite equivocal ultrasound findings, with a sensitivity of 97% and specificity of 90% for acute cholecystitis 1, 2.

The sonographic Murphy sign has relatively low specificity and its absence is unreliable, particularly if the patient received pain medication prior to imaging, according to the American College of Radiology 1, 2.
CT abdomen with IV contrast can identify complications of acute cholecystitis including gangrene, perforation, or adjacent liver parenchymal hyperemia 4, 5.
MRCP with contrast-enhanced MRI provides comprehensive evaluation and can distinguish acute from chronic cholecystitis based on T2 signal characteristics and wall enhancement patterns 4, 5.

Early surgical consultation is warranted given the acute presentation, as laparoscopic cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis, with the American College of Radiology recommending early cholecystectomy to reduce complications and hospital stay 1.