..... History

Patients with biliary colic present with acute onset of constant crampy pain in the right upper quadrant or epigastrium that may radiate to the back. Pain persisting for

more than 6 hours is unusual and should raise concern for

early cholecystitis. Nausea and vomiting are present to

varying degrees, and fever is usually absent.

Acute cholecystitis presents in much the same way as

biliary colic, but symptoms are persistent and localize to

the right upper quadrant. The pain may radiate to the right

or left shoulder owing to irritation of the diaphragm. Fever

CHAPTER 28

Table 28-1. Test characteristics of com mon historica l,

exam, and laboratory findings in acute cholecystitis.

Findings Sensitivity (%) Specificity (%)

Fever 35 80

Nausea 77 36

Emesis 71 53

RUQ pain 81 67

RUQ tenderness 77 54

Murphy sign 65 87

Leukocytosis (>12,000/ml) 63 57

RUQ, right upper quadrant.

Reproduced with permission from Roe J: Cli nical assessment of

acute cholecystitis in adults. Ann Emerg Med jul; 48(1 ): 1 01 -1 03,

2006.

may develop but it is often absent, especially in elderly or

immunosuppressed patients.

No historical or exam finding is adequately sensitive or

specific to exclude or confirm the diagnosis of cholecystitis

(Table 28- 1). The history should focus on previous episodes of similar symptoms and previous surgery. Patients

may describe exacerbations of pain related to food or late

at night. Although uncommon, patients who have had a

cholecystectomy can retain stones in the common bile duct

after surgery or develop them later. It is important to ask

about respiratory or cardiac symptoms to help exclude a

thoracic cause for the pain. Family history of gallstones,

female sex, parity, rapid weight loss, and hemolytic disorders are several important risk factors for gallstones .

..... Physical Examination

The physical examination should focus on excluding other

abdominal or thoracic causes of pain and determining the

degree of pain in the right upper quadrant. In biliary colic,

tenderness on examination may be mild. The Murphy sign

is the most specific physical exam finding for cholecystitis

and is described as the patient halting inspiration when the

examiner is palpating deeply in the right upper quadrant.

The examiner should also assess for costovertebral angle

tenderness and right lower quadrant tenderness.

DIAGNOSTIC STUDIES

..... Laboratory Studies

It is hard to discriminate biliary colic from early cholecystitis, and laboratory evaluation is almost always indicated.

A complete blood count ( CBC) may help in determining

the presence of infection, especially because fever may be

absent. However, the CBC may be normal in acute

cholecystitis. Liver function tests may help identify biliary

obstruction or hepatic inflammation. Serum lipase is helpful when there is a concern for choledocholithiasis and

associated gallstone pancreatitis.

.... Imaging