Signs of Cholecystitis
Most patients with acute cholecystitis present with right upper quadrant abdominal pain, nausea, vomiting, anorexia, and fever 1.
Clinical Presentation
The classic signs and symptoms of acute cholecystitis include:
Primary Clinical Features
- Right upper quadrant pain or tenderness - the most consistent finding, present in 56-93% of patients 2
- Murphy's sign - focal tenderness when palpating over the gallbladder during inspiration; has the strongest diagnostic value with a positive likelihood ratio of 15.64 (range 11.48-21.31) 2
- Fever - present in 31-62% of cases, though its absence does not exclude the diagnosis 2
- Nausea and vomiting - commonly associated symptoms 1, 3
- Anorexia or food intolerance - frequently reported 4
Laboratory Findings
- Elevated C-reactive protein - useful inflammatory marker 4
- Elevated white blood cell count (leukocytosis) - common but not always present 4, 5
- Elevated bilirubin - when present (40% sensitivity), has a positive likelihood ratio of 5.80, though specificity is 93% 2
Important Clinical Caveats
No single clinical or laboratory finding has sufficient diagnostic power to establish or exclude acute cholecystitis 4. The diagnosis requires a combination of clinical history, physical examination, laboratory tests, and imaging studies 4.
Critical pitfall: The sonographic Murphy's sign has relatively low specificity for acute cholecystitis 1, and its absence is unreliable as a negative predictor if the patient has received pain medication prior to imaging 1.
Atypical Presentations
Acute cholecystitis may not always present with classic findings 5. Some patients may have:
- Absence of fever 5
- Normal white blood cell count 5
- Negative Murphy's sign 5
- Atypical pain location (e.g., epigastric or anterior chest wall pain) 5
Imaging Findings
While not strictly "signs," imaging features that support the diagnosis include:
- Gallstones or sludge - present in 90-95% of cases 3
- Gallbladder wall thickening 1
- Pericholecystic fluid 1
- Sonographic Murphy sign - focal tenderness over the gallbladder during ultrasound examination 1
Ultrasound remains the initial imaging test of choice with 81% sensitivity and 83% specificity 3, though clinical history, physical examination, and laboratory tests alone do not yield sufficient diagnostic certainty for management decisions 1.