Can Acute Cholecystitis Present as Vomiting and Abdominal Pain?
Yes, acute cholecystitis commonly presents with both vomiting and abdominal pain, though the pain is typically localized to the right upper quadrant (RUQ) rather than being isolated vomiting alone. 1
Classic Presentation Pattern
Most patients with acute cholecystitis experience a constellation of symptoms including RUQ abdominal pain, nausea, vomiting, anorexia, and fever. 1 The key clinical features recognized by international guidelines include:
- RUQ pain - the predominant symptom 1
- Fever - commonly present 1
- Nausea and vomiting - occur in 38-48% of cases 2
- Murphy's sign - positive on examination 1
- Leukocytosis - supportive laboratory finding 1
Atypical Presentations: Important Clinical Pitfall
However, acute cholecystitis can present atypically without the classic diagnostic criteria, which is a critical pitfall to recognize. 3 A documented case demonstrated acute cholecystitis presenting with:
- Epigastric pain (rather than RUQ pain) 3
- Negative Murphy's sign 3
- No fever 3
- Normal WBC count 3
- Initial imaging (CT and ultrasound) showing no evidence of cholecystitis 3
This case was ultimately diagnosed via HIDA scan showing cystic duct obstruction, and intraoperatively revealed a severely distended, inflamed, and edematous gallbladder. 3
Can Isolated Vomiting Occur Without RUQ Pain?
While vomiting is a recognized component of acute cholecystitis, isolated vomiting without any abdominal pain would be highly atypical and should prompt consideration of alternative diagnoses. 1, 4 The typical presentation consists of acute RUQ pain with associated nausea and vomiting, rather than vomiting in isolation. 4
In elderly patients specifically, atypical presentations occur in only 12% of cases, and complete absence of pain is rare (5%). 2 This suggests that while presentations can vary, some form of abdominal discomfort is nearly always present.
Diagnostic Approach When Presentation is Unclear
When acute cholecystitis is suspected despite atypical features:
- Ultrasound remains the first-line imaging study with 81% sensitivity and 83% specificity 1, 5, 4
- If ultrasound is inconclusive, hepatobiliary scintigraphy (HIDA scan) is the gold standard with 97% sensitivity and 90% specificity 1, 3
- CT or MRI may identify complications when ultrasound findings are equivocal 5
Clinical history, physical examination, and routine laboratory tests alone do not yield sufficient diagnostic certainty for management decisions, making imaging studies essential. 1
Key Clinical Takeaway
While vomiting and abdominal pain are both common features of acute cholecystitis, the absence of RUQ pain, fever, or positive Murphy's sign does not exclude the diagnosis. 3 Maintain a high index of suspicion and proceed with appropriate imaging when clinical concern exists, as atypical presentations can occur and delay in diagnosis impacts outcomes. 3, 4