What are the typical signs and management of acute cholecystitis?

Physical Examination Findings in Acute Cholecystitis

Murphy's sign is the most characteristic physical examination finding in acute cholecystitis, along with right upper quadrant tenderness, fever, and in some cases, a palpable gallbladder mass. 1

Key Physical Examination Findings

• Murphy's sign: Pain with inspiration during palpation of the right upper quadrant, caused by the inflamed gallbladder coming into contact with the examiner's hand 1, 2
• Right upper quadrant pain and tenderness: Localized tenderness over the gallbladder area is a cardinal sign 1
• Fever: A systemic sign of inflammation commonly present in acute cholecystitis 1, 2
• Palpable gallbladder mass: May indicate a more complicated or advanced case of cholecystitis 1, 2
• Abdominal guarding: Involuntary muscle contraction in response to inflammation 1, 3

Diagnostic Approach

No single physical examination finding has sufficient diagnostic power to establish or exclude acute cholecystitis definitively. A combination of clinical, laboratory, and imaging findings is necessary for accurate diagnosis 1.

Clinical Assessment Algorithm:

1. Physical examination findings: Look for Murphy's sign, RUQ tenderness, fever 1, 2
2. Laboratory tests: Check for elevated white blood cell count and C-reactive protein 1
3. Imaging confirmation: Ultrasound is the first-line imaging modality 1

Ultrasound Findings in Acute Cholecystitis:

• Pericholecystic fluid
• Distended gallbladder
• Edematous gallbladder wall
• Gallstones (often impacted in cystic duct)
• Sonographic Murphy's sign (tenderness elicited during ultrasound examination) 1

Management Based on Physical Examination Findings

The severity of physical examination findings helps determine management:

Uncomplicated Cholecystitis:

• Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the treatment of choice 1, 3
• One-shot antibiotic prophylaxis if early intervention 1

Complicated Cholecystitis (indicated by severe tenderness, palpable mass, signs of sepsis):

• Laparoscopic cholecystectomy with antibiotic therapy for 4 days in immunocompetent patients 1
• Extended antibiotic therapy (up to 7 days) for immunocompromised or critically ill patients 1, 4

Special Considerations

• Elderly patients: Physical examination findings may be less pronounced despite severe disease 3, 4
• Immunocompromised patients: May have atypical presentation with minimal physical findings despite severe inflammation 1
• Pregnant patients: Right-sided abdominal pain and tenderness remain key findings, but early laparoscopic cholecystectomy is recommended regardless of trimester 3

Common Pitfalls in Physical Examination

• Murphy's sign may be absent in patients who have received pain medication prior to examination 1
• Relying solely on physical examination findings without laboratory or imaging confirmation can lead to missed diagnosis 1
• Physical examination alone has limited diagnostic accuracy - Murphy's sign has a positive likelihood ratio of only 2.8 (95% CI: 0.8-8.6) 1
• Acalculous cholecystitis (5-10% of cases) may present with similar physical findings but without gallstones on imaging 3

Physical examination remains a crucial first step in diagnosis, but must be integrated with laboratory and imaging findings for optimal patient outcomes 1, 3.