Sarah is a 45-year-old female who presents with abdominal pain localized to her epigastric and right upper quadrant that worsened after eating. She has a history of similar pain episodes and comorbidities of diabetes and hypercholesterolemia. On examination, she has tenderness in her epigastric and right upper quadrants with a positive Murphy's sign. Imaging reveals findings consistent with acute cholecystitis. She is started on antibiotics and supportive care and recommended for a laparoscopic cholecystectomy to treat her acute cholecystitis.

1. Case-based discussion
Calculus Acute Cholecystitis
Abdullah Ibrahim Bin Eid

2. Sarah is 45-year-old female from Saudi presents with a complaint
of abdominal pain for the past 3 days. She localizes the pain to her
epigastric area and states that it radiates to her right upper quadrant.
She notes that it became markedly worse after eating dinner last
night. She recalls a past history of similar pain, but has never had
any diagnostic workup.
Her past medical history is significant for DM II and
hypercholesterolemia. She is status post a total abdominal
hysterectomy 1 year ago.

3. HPI
The pain intermittent since 3 months.
usually last for 30 minutes then subsides gradually and Inc.
with fatty meals.
Nothing relieve it. It became continuous last 3 days.
Severity of pain 6/10

4. Associated symptoms
Nausea
Vomiting
Subjective fever

5. Unremarkable. Except for the subjected fever

6. • Dyslipidemia and DM II
• hysterectomy 1 year ago
• Works as a teacher in Riyadh
• Married (with 2 children)
• Not a smoker or alcoholic

7. ROS
Unremarkable

8. Vital signs
BP 101/90
HR 104
RR 14
T 38.1
SpO2 98%

9. PE
overweight woman in no acute distress. Her chest and
cardiovascular exams are normal except for mild tachycardia.
Her abdominal exam is significant for tenderness to palpation
to her epigastric and right upper quadrants without rebound
tenderness.
Bowel sounds are normal.
+ Murphy’s.

10. Investigations
CBC, LFT, Amylase.
AXR: unremarkable.
Transabdominal US “diagnostic”
HIDA scan

11. On US

12. DDx
1) Acute cholecystitis
2) Acute cholangitis (asso. w/ jaundice)
3) Gastric or duodenal ulcer

13. Management
broad-spectrum antibiotics and supportive therapy → surgical
management with cholecystectomy.
• Analgesia, Fluid and electrolyte correction and Antiemetics
• Abx:
Mild= ceftriaxone - if severe= piperacillin-tazobactam +/- Metro.

14. Surgical management
• Laparoscopic cholecystectomy is usually preferred.
• Timing
• In mild cases: elective cholecystectomy within 24–72 hours
• If complications are present (e.g., gangrene, perforation) or
condition worsens despite conservative therapy →
emergency cholecystectomy
• If high risk of surgical complications and/or critically ill →
emergency percutaneous biliary drainage (e.g., cholecystostomy)
→ follow up with interval surgery when possible.

15. Possible complications
• Emphysematous cholecystitis
• Gallbladder empyema
• Gallbladder gangrene (20%)
• Cholecystoenteric fistula
• Gallbladder perforation
Chronic cholecystitis:
• Porcelain gallbladder
• Gallbladder cancer

16. Thank you all
Any questions?