Acute Cholecystitis in the ED: From Colic to Crisis

-Case-

It’s a busy night in the ED when a 42-year-old woman comes in complaining of right upper quadrant pain that started after her last meal. The pain has been steadily worsening over the past 6 hours and she feels nauseated along with 2 episodes of non-bloody vomiting. On exam, she’s febrile at 100.9°F and she winces with pain when you palpate her RUQ. She abruptly halts her breath when you palpate under the right costal margin. 

-Evaluation-

Acute cholecystitis is inflammation of the gallbladder, most often due to cystic duct obstruction from gallstones. It’s a common cause of surgical abdominal pain and a diagnosis you don’t want to miss.

  • Classic presentation: right upper quadrant pain, fever, nausea/vomiting, positive Murphy’s sign (inspiratory arrest on RUQ palpation)
  • Risk factors: your classic cholecystitis patient is a female aged 40-60 with an elevated BMI that has a high-fat diet
  • Labs will classically reveal an elevated WBC count and a mildly elevated AST/ALT, bilirubin, or alk phos, often with a normal lipase (helps rule out pancreatitis)
  • Imaging is key! A Right Upper Quadrant ultrasound (RUQUS) is first-line and may demonstrate gallstones, gallbladder wall thickening (>3 mm), pericholecystic fluid, and/or a positive sonographic Murphy’s sign

-Management-

  1. Supportive care: think IV fluids, pain control (NSAIDs or opioids), and antiemetics
  2. Antibiotics: look to cover for gram-negatives and anaerobes; ceftriaxone + metronidazole, or Zosyn are often your best bet!
  3. Surgical consultation is key; cholecystectomy is the definitive treatment (usually within 24-72 hours), but a percutaneous cholecystostomy may be indicated for otherwise poor surgical candidates

-Fast Facts-

  • RUQUS is the go-to initial test!
  • Early surgery reduces complications and length of stay
  • Don’t confuse cholecystitis with biliary colic, which is transient and afebrile

Acute cholecystitis can masquerade as benign abdominal pain, but missing it can lead to perforation, sepsis, and major complications. Persistent RUQ pain, nausea, and fever should clue you into this pathology. Trust your exam, start your workup with an ultrasound, and don’t hesitate to get surgery involved early!

Want to learn more? Read our in-depth study guide on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Singer AJ, Thode HC Jr, Peacock WF. National trends in emergency department visits for cholelithiasis and cholecystitis, 1993-2012. Ann Emerg Med. 2015;65(2):177-181.e2. doi:10.1016/j.annemergmed.2014.07.007
  2. El-Banna A, Elnaggar A, Mohamed M, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Emerg Med. 2020;38(11):2252-2258. doi:10.1016/j.ajem.2020.06.001
  3. Nassar AH, Ashkar KA, Rashed AA, et al. Gallbladder wall thickening in acute cholecystitis: diagnostic value of ultrasound. Emerg Radiol. 2014;21(6):571-576. doi:10.1007/s10140-014-1246-9
  4. Yokoe M, Takada T, Hwang TL, et al. TG13 guidelines for diagnosis and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20(1):35-46. doi:10.1007/s00534-012-0568-9
  5. Pinto A, Reginelli A, Cagini L, et al. Accuracy of ultrasonography in the diagnosis of acute cholecystitis in the emergency setting: review of the literature. Crit Ultrasound J. 2013;5(Suppl 1):S11. doi:10.1186/2036-7902-5-S1-S11
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