From the Guidelines
Acute cholecystitis presenting with Murphy's sign should be managed with early laparoscopic cholecystectomy, ideally within 24-72 hours of presentation, as it is a safe and effective treatment that reduces complications and hospital stay compared to delayed intervention 1. The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, with ultrasound being the investigation of choice 1. Some key points to consider in the management of acute cholecystitis include:
- Initial management with NPO status, IV fluids, pain control, and broad-spectrum antibiotics such as Piperacillin-Tazobactam or Ceftriaxone plus Metronidazole 1
- Definitive treatment with cholecystectomy, which can be performed laparoscopically or openly, depending on the patient's condition and the surgeon's expertise 1
- Early surgery is recommended, as it reduces complications and hospital stay compared to delayed intervention 1
- For patients unfit for surgery, percutaneous cholecystostomy tube placement may serve as a temporizing measure until definitive treatment can be performed 1
- The sensitivity and specificity of Murphy's sign in the diagnosis of acute cholecystitis are moderate and high, respectively, with a sensitivity of 65-70% and a specificity of 87-96% 1
- Laboratory findings typically include leukocytosis, mildly elevated liver enzymes, and occasionally elevated bilirubin 1
- Clinical features such as pain, fever, abdominal defense, and vomiting are common in patients with acute cholecystitis, but may be atypical or absent in elderly patients 1
From the Research
Acute Cholecystitis Presentation
- Acute cholecystitis is a common presentation of gallbladder disease, affecting approximately 20 million individuals in the US, with an incidence of around 200,000 cases per year 2, 3.
- The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea, which may be associated with eating, and physical examination findings of right upper quadrant tenderness 3, 4.
- However, acute cholecystitis may not always present with the classic diagnostic criteria, including laboratory results and physical exam findings, such as fever, RUQ pain, and a positive Murphy's sign 2.
Murphy's Sign in Acute Cholecystitis
- Murphy's sign is a useful diagnostic tool for acute cholecystitis, with a positive predictive value of 0.58, sensitivity of 0.48, and specificity of 0.79 in elderly patients 5.
- However, a negative Murphy's sign should be treated with caution, and other diagnostic tests should be promptly performed, especially in elderly patients 5.
- The presence or absence of Murphy's sign can affect the initial diagnosis of acute cholecystitis, with a diagnostic accuracy of 80% when the sign is present, dropping to 34% when the sign is negative 5.
Diagnostic Approaches
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 3.
- Hepatobiliary scintigraphy is the gold standard diagnostic test when an ultrasound result does not provide a definitive diagnosis 3.
- Computed tomography and magnetic resonance imaging are commonly performed to identify complications, and cholescintigraphy is recommended in patients with equivocal findings on other imaging modalities 4.
Management of Acute Cholecystitis
- Laparoscopic cholecystectomy is considered the gold-standard treatment for acute cholecystitis, with early surgery (performed within 1-3 days) associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 3, 6.
- Percutaneous cholecystostomy tube placement is an effective therapy for patients with an exceptionally high perioperative risk, but it is associated with higher rates of postprocedural complications compared with laparoscopic cholecystectomy 3, 6.