In a patient with right‑upper‑quadrant pain, nausea/vomiting and a history of gallstones, what does a partially contracted gallbladder on ultrasound indicate and how should it be managed?

Partially Contracted Gallbladder: Clinical Significance and Management

A partially contracted gallbladder on ultrasound in a patient with right upper quadrant pain, nausea/vomiting, and known gallstones most likely indicates chronic cholecystitis with intermittent cystic duct obstruction, and you should proceed with surgical consultation for laparoscopic cholecystectomy as definitive management. 1, 2

Understanding the Finding

A partially contracted gallbladder represents a critical diagnostic clue in the context of symptomatic gallstone disease:

• In chronic cholecystitis, a contracted gallbladder with stones is seen in 15% of cases, compared to only 1% in acute cholecystitis. 3 This finding strongly suggests chronic rather than acute inflammation in your patient.

• The partial contraction indicates the gallbladder is attempting to empty against an obstructed or dysfunctional cystic duct, which is the primary pathogenic mechanism underlying both acute and chronic cholecystitis. 1

• When combined with gallstones and typical symptoms, this finding has high clinical significance—only 1% of patients with operatively confirmed cholecystitis have completely normal ultrasound findings. 3

Immediate Diagnostic Steps

Order right upper quadrant ultrasound evaluation for additional findings beyond the contracted gallbladder: 2

• Look for gallbladder wall thickening (>3mm), which is present in 80% of acute cholecystitis but only 18% of chronic cases 3
• Assess for pericholecystic fluid, wall sonolucency, and gallbladder distension 2
• Document the sonographic Murphy sign, though its absence (particularly if pain medication was given) does not exclude cholecystitis 1, 2
• At least 2 ultrasound abnormalities are required to establish the diagnosis of acute cholecystitis 2

When Additional Imaging Is Needed

If ultrasound findings are equivocal despite high clinical suspicion, order a HIDA scan: 1, 2

• HIDA scan has 97% sensitivity and 90% specificity for acute cholecystitis 1, 2
• This is particularly valuable when the gallbladder appears contracted but other inflammatory signs are absent 1
• Non-visualization of the gallbladder on HIDA scan confirms cystic duct obstruction 1

MRCP with IV gadolinium contrast should be ordered if: 4

• You need to evaluate the biliary tree for choledocholithiasis (sensitivity 85-100%, specificity 90%) 4
• Liver function tests are elevated, suggesting possible common bile duct obstruction 4
• You need to distinguish between acute and chronic cholecystitis based on wall enhancement patterns 1

Clinical Management Algorithm

Proceed with early surgical consultation for laparoscopic cholecystectomy: 1, 2

• This is the definitive treatment for both acute and chronic symptomatic cholecystitis 1, 2
• Early cholecystectomy within 7-10 days of symptom onset reduces complications and hospital stay 2
• The presence of symptoms (RUQ pain, nausea/vomiting) with documented gallstones makes this patient a clear surgical candidate 2

If acute cholecystitis is confirmed, initiate antibiotic therapy: 2

• Use amoxicillin/clavulanate, eravacycline, or tigecycline for 2-4 days if source control is adequate 2
• However, antibiotics are adjunctive—surgery remains the definitive treatment 2

Critical Pitfalls to Avoid

Do not dismiss the contracted gallbladder as a "normal variant"—in the context of symptoms and gallstones, this finding has pathologic significance. 3 The combination of a contracted gallbladder with stones in a symptomatic patient represents chronic cholecystitis until proven otherwise.

Do not rely solely on the absence of fever or elevated white blood cell count to exclude cholecystitis. 2 No single clinical or laboratory finding has sufficient diagnostic power to establish or exclude the diagnosis.

Do not order a HIDA scan to evaluate for biliary dyskinesia or calculate ejection fraction in this patient. 5 The diagnostic value of cholescintigraphy with CCK stimulation in patients with chronic RUQ pain is low, and a low ejection fraction does not predict clinical outcome after cholecystectomy. 5 Your patient has documented gallstones with typical symptoms—this is straightforward symptomatic cholelithiasis requiring cholecystectomy, not functional gallbladder disorder.

Avoid ordering CT as the primary advanced imaging modality. 4 CT has lower sensitivity (39-75%) for detecting gallstones compared to ultrasound, and many gallstones are non-calcified and invisible on CT. 4 Reserve CT for critically ill patients with suspected complications like perforation or abscess. 4