This patient presented with right upper quadrant pain that began as dull midepigastrium pain and later moved to the RUQ and flank. He vomited brown fluid and was unable to eat. Examination revealed tenderness in the RUQ and Murphy's sign. Ultrasound could not identify the gallbladder initially but was later seen on radiology ultrasound with stones. Laboratory results showed elevated WBC, glucose, ALT, AST, and lipase. The diagnosis was acute cholecystitis confirmed by ultrasound findings of gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy's sign.

3. CHOLECYSTITIS

4. CASE REVIEW

5. A 71-year-old man presented to the ED with right upper quadrant
pain of two day’s duration.
The pain began as a dull ache in the midepigastrium and then
moved to the right upper quadrant and right flank. He vomited
several times and was unable to eat. The emesis was a watery
brown material. He had a small bowel movement earlier that
day.
He had a history of diabetes and hypertension and was taking
glyburide and lisinopril.
He had not had prior abdominal surgery.
On examination, he was overweight and in mild distress due
to abdominal discomfort. His blood pressure was 148/100 mm Hg,
pulse 110 beats/min, respiratory rate 24 breaths/min, temperature
100.4 F (rectal).
He was alert and oriented. His oral mucosa was dry and sclera was
anicteric. His lungs were clear and his heart wasr apid and regular
without a murmur

6. Abdominal examination revealed diminished bowel sounds,
moderate tenderness in the right upper quadrant, and a Murphy’s
sign. There was no tenderness on rectal examination and
stool was guiac negative.
An intravenous line was started and blood specimens were
obtained. Intravenous fluids, insulin, and ampicillin/sulbactam
were administered
Blood test results (units for electrolytes, mEq/L and chemistry
values, mg/dL, except where noted):
WBC 19,700/mm3, hematocrit 49%, platelets 246,000/mm3.
Na 132, K 4.1, Cl 101, CO2 22, BUN 24, creatinine
1.4, glucose 406.
ALT 100 U/L (normal: 7–37), AST 65 U/L, alkaline phosphatase
61 U/L (normal: 39–117), total bilirubin 1.6
(normal: 0.2–1.2), lipase 110 U/L (normal).
A bedside sonogram was performed and the gallbladder could
not be confidently identified. The patient was sent to the radiology
department for another abdominal ultrasound study. Selected
ultrasound images, including the right upper quadrant,
are shown in Figure 1.

9. TYPICAL SONOGRAPHIC
APPEARANCE OF
GALLSTONE

12. UNDER WHAT CIRCUMSTANCES
WOULD THE GALLBLADDER NOT
HAVE ITS TYPICAL APPEARANCE?

13. • When patient has recently eaten.
• Multiple episodes of cholecystitis (scarred and
shrunken)
• Filled w/stones or contracted around
gallstones
• Air filled gallblader (empysematouse
cholecystitis)

14. WALL-ECHO-SHADOW (WES) OR DOUBLE ARC

18. EMPHYSEMATOUS CHOLECYSTITIS

19. • Emphysematous cholecystitis < 1%
• ATC: elderly, male, dbt
• Mortality rate: 15% (1.4 cholecystitis)
• TTO: CX because of perforation
• Test of choice: Abdominal RX

21. • Air in the biliary system also occurs w/ enteric-
biliary fistula (gallstone ileus or surgical
anastomosis)
– Gallbladder is collpased rather than distended

22. GAS IN THE GALLBLADDER WALL IS
PATHOGNOMONIC FOR
EMPHYSEMATOUS CHOLECYSTITIS

23. BEST INITIAL TEST?
• ULTRASONOGRAPHY : bright echogenic
crescent in the gallbladder fossa with dirty
shadowing and ring down artifacts.
– Similar:
• Contracted stone-filled gallbladder (WES)
• Porcelain gallbladder w/ calcified wall due to chronic
cholecystitis
• CONFIRMATION:
– Abdominal rx or CT

25. IMAGING DIAGNOSIS OF ACUTE
CHOLECYSTITIS
• Abdominal rx: 15% stones calcified
• Ultrasound : > sensitive
• Symptomatic:
– 80% without

27. DIAGNOSIS OF ACUTE CHOLECYSTITIS
• CLINICAL PRESENTATION
• SIGNS OF GALLBLADDER INFLAMATION ON
SONOGRAPHY OR CT
– GALLBLADDER WALL THICKENING (>3 TO 5MM)
– PERICHOLECYSTIC FLUID
– SONOGRPHIC MURPHY’S SIGN

29. CLINICAL PRESENTATION!
Persitant pain
Focal tenderness
Murphy sign
Leukocytosis
Fever