How should I manage an adult with suspected acute cholecystitis presenting with right upper quadrant (RUQ) pain, fever, and a positive Murphy’s sign?

Management of Acute Cholecystitis

Immediately obtain a right upper quadrant ultrasound to confirm the diagnosis, initiate antibiotic therapy, and arrange for early laparoscopic cholecystectomy within 7-10 days of symptom onset. 1, 2

Diagnostic Confirmation

Your clinical presentation with RUQ pain, fever, and positive Murphy's sign strongly suggests acute cholecystitis, but ultrasound imaging is mandatory and must be performed immediately to confirm the diagnosis before proceeding with definitive management. 1, 2

Key Ultrasound Findings to Identify:

• Gallstones or sludge (present in 90-95% of acute cholecystitis cases) 3
• Gallbladder wall thickening >3mm 1
• Pericholecystic fluid 1
• Gallbladder distension 1
• Sonographic Murphy's sign (focal tenderness when probe compresses the gallbladder) 4, 1
• Stones impacted in the gallbladder neck or cystic duct 1

At least 2 ultrasound findings are required to establish the diagnosis, as ultrasound has 88% sensitivity and 80% specificity for acute cholecystitis. 1

Important Diagnostic Caveats:

• Do not rely on a single clinical or laboratory finding to establish or exclude the diagnosis, as no single feature has sufficient diagnostic power. 4
• The absence of fever or leukocytosis does not exclude acute cholecystitis—some patients present with atypical laboratory findings. 4, 5
• Murphy's sign has a positive likelihood ratio of only 2.8 with relatively low specificity, and may be falsely negative if the patient received pain medication prior to examination. 4, 1

If Ultrasound is Equivocal or Negative:

Proceed to hepatobiliary scintigraphy (HIDA scan), which is the gold standard diagnostic test with 97% sensitivity and 90% specificity for acute cholecystitis. 1, 6, 3 The HIDA scan will demonstrate cystic duct obstruction if acute cholecystitis is present. 5

Alternatively, CT abdomen with IV contrast can identify complications including gangrene, perforation, gas formation, and adjacent liver parenchymal hyperemia, while also evaluating for alternative diagnoses. 6, 7

Immediate Management Algorithm

Step 1: Initiate Antibiotic Therapy

Start antibiotics immediately upon diagnosis:

• First-line options: Amoxicillin/clavulanate, eravacycline, or tigecycline 1, 2
• For critically ill or immunocompromised patients: Piperacillin/tazobactam or eravacycline 2
• Duration: 2-4 days if source control is adequate in immunocompetent patients; up to 7 days in immunocompromised or critically ill patients 1, 2

Step 2: Obtain Immediate Surgical Consultation

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment and is associated with improved outcomes compared to delayed surgery. 1, 2, 3

Early surgery (within 1-3 days) compared to late surgery (after 3 days) results in:

• Fewer postoperative complications (11.8% vs 34.4%) 3
• Shorter hospital stay (5.4 days vs 10.0 days) 3
• Lower hospital costs 3

Single-shot antibiotic prophylaxis is sufficient if early intervention is performed. 2

Step 3: Supportive Care

• Intravenous hydration 5
• Bowel rest 5
• Analgesia 5

Special Populations and Alternative Management

High-Risk Surgical Patients:

Percutaneous cholecystostomy may be considered for patients with multiple comorbidities who do not show clinical improvement after antibiotic therapy, followed by 4 days of antibiotic treatment. 2 However, this approach is associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%), so it should be reserved for patients with exceptionally high perioperative risk. 3

Elderly Patients (>65 years):

Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%), making surgery the preferred approach even in this population. 3

Pregnant Patients:

Early laparoscopic cholecystectomy is recommended during all trimesters and is associated with lower maternal-fetal complications (1.6% for early vs 18.4% for delayed). 3

Severity Assessment

Classify the severity to guide management intensity:

• Grade I (Mild): No organ dysfunction, limited gallbladder disease, low-risk cholecystectomy 8
• Grade II (Moderate): No organ dysfunction but extensive gallbladder disease (elevated WBC, palpable tender mass, symptoms >72 hours, significant inflammatory changes on imaging) 8
• Grade III (Severe): Acute cholecystitis with organ dysfunction 8

Red Flags Requiring Urgent Intervention

• Marked leukocytosis with fever: Raises concern for empyema or complicated cholecystitis 6
• Elevated alkaline phosphatase or bilirubin: Suggests biliary obstruction and warrants advanced imaging 6
• Ongoing signs of infection beyond 7 days of antibiotic treatment: Warrants diagnostic investigation for complications or alternative diagnoses 2