Acute Cholecystitis: Diagnosis and Management
Written by Dr. Muhammad Salar Raza · Manually reviewed by Dr. Muhammad Salar Raza · Content updated
Clinical Pathway
Suspect acute cholecystitis with prolonged right upper quadrant or epigastric pain, fever, and a positive Murphy sign, typically after fatty meals in a patient with gallstone risk factors. Confirm with right upper quadrant ultrasound showing gallstones, wall thickening, pericholecystic fluid, or a sonographic Murphy sign. Initial management is nil by mouth, intravenous fluids, analgesia, and antibiotics covering enteric organisms, such as ceftriaxone plus metronidazole. Early laparoscopic cholecystectomy within the index admission is the definitive treatment for fit patients. High-risk surgical candidates may need percutaneous cholecystostomy for drainage. Distinguish complications: empyema, gangrene, perforation, and ascending cholangitis with Charcot triad.
Clinical Reasoning
Biliary colic resolves within hours, while pain persisting beyond 6 hours with fever and Murphy sign indicates cholecystitis; this duration distinction decides between observation and admission. Ultrasound is first-line because it is sensitive for stones and wall changes, with HIDA scan reserved for equivocal cases. Charcot triad of pain, fever, and jaundice points to cholangitis, which requires urgent biliary drainage by ERCP rather than cholecystectomy alone. Murphy sign is invalidated mid-way if the patient has generalized peritonitis from perforation. In diabetics and the elderly, gangrenous cholecystitis can present blandly, so maintain a low threshold for surgical review.
Sample MCQ
A 45-year-old woman has 10 hours of right upper quadrant pain after a fatty meal, fever 38.4 degrees Celsius, and a positive Murphy sign. White cell count is elevated. What is the most appropriate initial imaging investigation?
- ARight upper quadrant ultrasound
- BHIDA scan as the first test
- CMRCP
- DPlain abdominal X-ray
Correct Answer: Right upper quadrant ultrasound
Ultrasound is the first-line investigation for suspected acute cholecystitis because it detects gallstones, gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy sign at the bedside, quickly and without radiation. HIDA scan is more specific for cystic duct obstruction but is reserved for equivocal ultrasound findings, not first-line. MRCP evaluates the bile ducts for choledocholithiasis when jaundice or duct dilation suggests a stone in the common bile duct, which is not the primary question here. Plain X-ray shows only a small minority of gallstones and cannot assess the gallbladder wall, so it has no diagnostic role.
Guidelines and further reading
Related Clinical Topics
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