From the Guidelines
Physical assessments for a possible acute gallbladder attack (acute cholecystitis) should include evaluating for right upper quadrant abdominal pain, Murphy's sign, fever, jaundice, and abdominal tenderness, as these are the most useful features for diagnosis, according to the 2020 World Society of Emergency Surgery updated guidelines 1. The diagnosis of acute cholecystitis (AC) involves a combination of detailed history, complete clinical examination, laboratory tests, and imaging investigations. Key physical assessments include:
- Evaluating for right upper quadrant abdominal pain, which typically intensifies after meals, especially fatty ones
- Checking for Murphy's sign by placing fingers under the right costal margin and asking the patient to take a deep breath; a positive sign occurs when the patient stops breathing due to pain when the inflamed gallbladder contacts the examiner's fingers
- Checking for fever, which may indicate infection
- Jaundice (yellowing of skin or sclera), suggesting bile duct obstruction
- Palpating for abdominal tenderness, guarding, or rigidity
- Monitoring vital signs for tachycardia and hypertension, which may indicate pain or systemic inflammatory response
- Referred pain to the right shoulder (Collins' sign) or back These assessments help distinguish acute cholecystitis from other conditions like appendicitis, peptic ulcer disease, or pancreatitis. Early recognition is crucial as delayed treatment can lead to complications such as perforation, gangrene, or sepsis, potentially requiring emergency surgical intervention rather than the preferred elective cholecystectomy. The use of abdominal US as the initial imaging technique is recommended due to its widespread availability, lack of invasiveness, and reduced costs, despite its variable sensitivity and specificity 1. Imaging investigations such as US, CT with IV contrast, and magnetic resonance cholangiopancreaticography (MRCP) can also be used to support the diagnosis 1.
From the Research
Physical Assessments for Possible Acute Gallbladder Attack
- The clinical presentation of acute cholecystitis (AC) typically includes severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphy's sign with an elevated white blood cell count 2.
- A physical examination may reveal tenderness in the right upper quadrant of the abdomen, and a positive Murphy's sign is highly suggestive of acute cholecystitis 2.
- Laboratory results, such as an elevated white blood cell count, can also support the diagnosis of acute cholecystitis 3, 2.
- Imaging studies, including ultrasonography, computed tomography, and magnetic resonance imaging, are commonly used to confirm the diagnosis and identify complications 4, 5, 2.
- The sonographic findings, such as gallbladder distention, gallbladder wall thickness, and sludge, can be recorded on a 3-point scale to support the diagnosis of acute acalculous cholecystitis (AAC) 3.
Diagnostic Evaluation
- Ultrasonography is the initial imaging modality of choice for the evaluation of suspected acute gallbladder disorders, and is often sufficient for correct diagnosis 4.
- Computed tomography (CT) plays a vital role in the evaluation of acute gallbladder pathology, particularly in situations where ultrasound findings are equivocal 4.
- CT is also extremely valuable in the assessment of suspected complications of acute cholecystitis, such as emphysematous cholecystitis, hemorrhagic cholecystitis, and gallbladder perforation 4.
- Cholescintigraphy is recommended in patients with equivocal findings on other imaging modalities, as this technique has the highest diagnostic accuracy in the diagnosis of AC 2.
Risk Factors for Severe Gallbladder Complications
- Older patients with a high white cell count are more likely to have severe gallbladder complications, such as perforation, gangrene, or abscess 3.
- Patients with acute acalculous cholecystitis (AAC) are at high risk for severe gallbladder complications, and prompt therapy should be initiated to prevent these complications 5.