Snapshot A 45-year-old obese woman presents to the emergency room with steady, severe, aching pain in the upper right quadrant that radiates to the right scapula. The onset was acute and occurred 30 minutes after lunch. She also reports nausea with vomiting. On physical exam, it is noted that she stops breathing on deep palpation of the right quadrant. Laboratory studies show an absolute neutrophillic leukocytosis with a left shift. Introduction Clinical definitionacute inflammation of the gallbladder, often in the setting of gallstones or biliary sludgeacalculous cholecystitisetiologygallbladder stasishypoperfusioninfectionoften seen invery ill patientsassociated with high mortalitycalculous cholecystitisetiologygallstone impaction resulting in inflammationmore commonEpidemiologydemographicsfemale > maleadultsrisk factorsgallstonesF'sFatFemaleFortyFlatulentFertilehormone replacement therapyobesityhypertriglyceridemiaetiologyEEEK bugsE. coliEnterobacterEnterococcusKlebsiellaPathogenesisblockage of cystic duct by gallstones can lead to distention of gallbladder, inflammation, and infection Presentation Symptoms systemic symptoms fevers chills nausea and vomiting anorexia right upper quadrant pain may radiate to shoulder Physical exam inspection jaundice typically not seen Charcot triad may indicate progression of disease to ascending cholangitis login to view 3 more bullets palpation right upper quadrant tenderness to palpation peritoneal signs may indicate perforation gallbladder may be palpable tests Murphy sign login to view 1 more bullet Boas sign login to view 1 more bullet Imaging Right upper quadrant ultrasound best initial imaging findings stones biliary sludge thickened gallbladder wall ultrasonic Murphy sign Cholescintigraphy (HIDA scan) indication ultrasound findings are equivocal findings lack of gallbladder visualization Computed tomography (CT) of abdomen and pelvis indication to rule out other abdominal pathologies findings gallbladder distention thickened gallbladder wall pericholecystic fat stranding abscesses Studies Studies ↑ or normal alkaline phosphatase ↑ or normal bilirubin ↑ or normal white blood cell count Diagnostic criteria local inflammation Murphy sign right upper quadrant tenderness systemic inflammation fever ↑ white blood cell count imaging cholecystitis Differential Acute pancreatitis distinguishing factor usually has elevated lipase and epigastric tenderness may be associated with gallstones Treatment First-line supportive care intravenous fluids electrolyte repletion analgesia intravenous antibiotics non-emergent cholecystectomy indication login to view 1 more bullet emergent cholecystectomy indication login to view 2 more bullets Second-line percutaneous drainage indication login to view 1 more bullet Complications Ascending cholangitis Gallbladder perforation