How should I evaluate and treat an adult with suspected acute calculous cholecystitis presenting with right upper quadrant pain, fever, leukocytosis, and a positive Murphy's sign?

Evaluation and Treatment of Acute Calculous Cholecystitis

For an adult presenting with right upper quadrant pain, fever, leukocytosis, and positive Murphy's sign, proceed immediately with ultrasound confirmation and plan for early laparoscopic cholecystectomy within 1-3 days of diagnosis, as this approach reduces complications, shortens hospitalization, and improves outcomes compared to delayed surgery. 1, 2

Diagnostic Approach

Initial Clinical Assessment

• Murphy's sign has limited diagnostic power (positive likelihood ratio 2.8) and should never be used in isolation to confirm or exclude acute cholecystitis 3
• The sign may be falsely negative if the patient received pain medication prior to examination, making timing of assessment critical 4, 3
• Elderly, diabetic, or immunocompromised patients may lack Murphy's sign despite severe gallbladder disease 3
• The classic triad of right upper quadrant pain, fever, and leukocytosis is nonspecific and insufficient for diagnosis 5, 2

Imaging Strategy

• Ultrasound is the mandatory first-line imaging test with 96% accuracy for detecting gallstones and 81% sensitivity for acute cholecystitis 1, 3, 2
• Look specifically for: pericholecystic fluid, distended gallbladder, edematous gallbladder wall (>3mm), gallstones, and sonographic Murphy's sign 1
• Sonographic Murphy's sign (tenderness when probe compresses the gallbladder) combined with gallstones has 92% positive predictive value 4
• If ultrasound is negative or equivocal, hepatobiliary scintigraphy (HIDA scan) is the gold standard confirmatory test 1, 2
• MRI with MRCP is superior to CT for biliary evaluation (85-100% sensitivity for stones) and can distinguish acute from chronic cholecystitis based on T2 signal characteristics 1
• CT has limited value as initial imaging (only 75% sensitivity for gallstones) but may identify complications like perforation or gangrene 1

Laboratory Considerations

• Procalcitonin >0.09 ng/mL at admission predicts major surgical complications with 84.8% sensitivity, including need for open conversion 5
• No single laboratory test has sufficient diagnostic power; use the combination of clinical findings plus imaging 3

Treatment Algorithm

Timing of Surgery

• Early laparoscopic cholecystectomy (within 1-3 days of diagnosis) is superior to delayed surgery and should be performed regardless of symptom duration 1, 2
• Early surgery reduces composite postoperative complications (11.8% vs 34.4% for delayed), shortens hospital stay (5.4 vs 10.0 days), and lowers costs 1, 2
• This approach applies to all age groups, including elderly patients over 65 years who have lower 2-year mortality with surgery (15.2%) versus nonoperative management (29.3%) 2

Surgical Approach

• Standard laparoscopic cholecystectomy (3-4 port technique) is the definitive treatment with low mortality and morbidity 6
• If source control is complete with cholecystectomy in uncomplicated cases, no postoperative antibiotics are necessary 4

Alternative Management

• Percutaneous cholecystostomy should be reserved only for patients with exceptionally high perioperative risk 2
• This drainage approach has significantly higher postprocedural complications (65%) compared to laparoscopic cholecystectomy (12%) 2
• Consider cholecystostomy only as a temporizing measure in severely unstable patients, not as routine alternative therapy 7, 8

Special Populations

• Pregnant patients should undergo early laparoscopic cholecystectomy during any trimester, as this reduces maternal-fetal complications (1.6% vs 18.4% for delayed management) 2
• Patients with severe comorbidities still benefit from surgical intervention over conservative management 6, 2

Critical Pitfalls to Avoid

• Do not delay surgery waiting for inflammation to "cool down"—the delayed approach (6-12 weeks) is outdated and associated with worse outcomes 1
• Do not rely on negative Murphy's sign to exclude cholecystitis, especially after analgesic administration 4, 3
• Do not use CT as first-line imaging; it misses 25% of gallstones and provides inferior biliary system evaluation 1
• Do not routinely place percutaneous cholecystostomy tubes as primary therapy; reserve this only for the most critically ill patients who cannot tolerate any surgery 2
• Maintain low threshold for conversion to open surgery when anatomy is unclear—bile duct injuries are the most serious complication and result from inadequate visualization 6