History
The most common presenting symptom of acute cholecystitis is upper abdominal pain. In some patients, the pain may radiate to the right shoulder or scapula. Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant (RUQ). Although the pain may initially be described as colicky, it is not a true colic and becomes constant in virtually all cases. Nausea and vomiting are generally present, and patients may report fever.
Most patients with acute cholecystitis describe a history of biliary pain. Some patients may have already documented gallstones. Acalculous biliary colic also occurs, most commonly in young to middle-aged females. The presentation is almost identical to calculous biliary colic with the exception of reference range laboratory values and no findings of cholelithiasis on ultrasound. Cholecystitis is differentiated from biliary colic by the persistence of constant severe pain for more than 6 hours.
Patients with acalculous cholecystitis may present similarly to patients with calculous cholecystitis, but acalculous cholecystitis frequently occurs suddenly in severely ill patients without a prior history of biliary colic. Often, patients with acalculous cholecystitis may present with fever and sepsis alone, without a history or physical examination findings consistent with acute cholecystitis.
Cholecystitis in elderly persons
Elderly patients (especially patients with diabetes) may present with vague symptoms and without many key historical and physical findings. Pain and fever may be absent, and localized tenderness may be the only presenting sign. Elderly patients may also progress to complicated cholecystitis rapidly and without warning.
Cholecystitis in children
The pediatric population may also present without many of the classic findings. Children who are at a higher risk for developing cholecystitis include patients with sickle cell disease, seriously ill children, those on prolonged total parenteral nutrition, those with hemolytic conditions, and those with congenital and biliary anomalies. [16] For more information, see the Medscape Drugs & Diseases article Pediatric Cholecystitis.
Physical Examination
The physical examination may reveal fever, tachycardia, and signs of peritoneal irritation (eg, tenderness in the right upper quadrant [RUQ] or the epigastric region), often with guarding or rebound. The Murphy sign, described as tenderness and an inspiratory pause elicited during palpation of the RUQ as the patient takes a deep breath, is widely used in the diagnosis of acute cholecystitis. [66] Some debate exists over the sensitivity of the Murphy sign, with some sources citing a very low sensitivity (20%) and others indicating a sensitivity range of 58%-71% (systematic review) and 48%-97% (evidence-based review). [64, 65] The sonographic Murphy sign, however, remains an important sign of cholecystitis. [66, 67, 68, 69, 70] (See Workup, Ultrasonography.)
A palpable gallbladder or fullness of the RUQ is present in 30%-40% of cases. Jaundice may be noted in approximately 15% of patients.
The absence of physical findings does not rule out the diagnosis of acute cholecystitis. Many patients present with diffuse epigastric pain without localization to the RUQ. Patients with chronic cholecystitis frequently do not have a palpable RUQ mass because of fibrosis leading to a contracted gallbladder.
Elderly patients and patients with diabetes frequently have atypical presentations, including the absence of fever and localized tenderness with only vague symptoms.
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Acute Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.
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Acute Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.
