Cholecystitis: Clinical sciences

Acute cholecystitis is a sudden inflammation of the gallbladder, usually caused by conditions that impair the outflow of bile. Think of the biliary tree as one of the many plumbing systems in the body! Disrupted bile outflow increases the pressure within the gallbladder, leading to bile stasis. This in turn can lead to complications such as inflammation, infection, gangrene, and perforation. Acute cholecystitis is most commonly related to a stone, which is called calculous cholecystitis. However, gallbladder inflammation can also occur without stones, which is known as acalculous cholecystitis.

When assessing a patient with suspected acute cholecystitis, first you should determine if your patient is stable or unstable by doing an ABCDE assessment. If the patient is unstable, you should stabilize them first, which means that you might need to intubate the patient, establish IV access, or administer fluids before continuing with your assessment.

After completing those important steps, you should obtain a history and physical exam, as well as labs such as CBC, ESR, CRP, and CMP, which includes ALP, GGT, ALT, AST, and total bilirubin; also obtain lactate, and blood cultures, as well as amylase and lipase to rule out pancreatic involvement. The history usually reveals symptoms like nausea, vomiting, and right upper quadrant or epigastric abdominal pain that might radiate to the shoulder or scapula; symptoms typically occur after eating a high fat meal.

On a physical exam, you might find signs such as tenderness to palpation in the right upper quadrant, with a positive Murphy sign. You can elicit Murphy sign by palpating the right upper quadrant while asking the patient to take a deep breath. If the pain stops inspiration, Murphy sign is considered positive. Additional findings on physical exam include jaundice, fever, and signs of hemodynamic instability like tachycardia and hypotension. These systemic signs are more common in those with severe disease.