Clinical presentation: how to recognize an attack
The disease manifests with a characteristic pain syndrome. The pain appears suddenly, is severe and constant in nature. The classic localization is the right upper quadrant, but the discomfort rarely remains confined to a single area. Pain typically radiates to the back—most commonly to the region of the inferior angle of the right scapula, and also extends to the right supraclavicular region and the right half of the neck.
The development of an acute attack is usually associated with triggering factors. The main triggers include dietary indiscretions (heavy fatty or spicy food), alcohol intake, and severe emotional stress.
In addition to pain, patients suffer from pronounced nausea and vomiting that brings no relief.
On objective physical examination, the physician notes:
- Signs of general intoxication (fever).
- Possible mild jaundice.
- Sharp tenderness upon palpation of the abdomen in the right upper quadrant.
- Involuntary guarding of the anterior abdominal wall muscles (defénse musculaire).
- Positive specific gallbladder signs.
Red flags and complications
It is crucial to closely monitor the dynamics of the patient's condition against the background of ongoing therapy. If the pain syndrome does not subside, and the fever and signs of intoxication increase, this is a direct indication of the development of destructive processes in the organ.
Dangerous complications include:
- Cholangitis — spread of infection and inflammation to the bile ducts.
- Gallbladder empyema — accumulation of pus in an isolated cavity of the organ.
- Perforation and peritonitis — breach of the gallbladder wall integrity with the release of infected contents into the abdominal cavity.
Diagnostic workup
Diagnosis is based on a combination of laboratory and instrumental data.
Laboratory markers:
- Complete blood count: reveals leukocytosis with a left shift (band neutrophil shift), confirming an acute bacterial or aseptic inflammatory process.
- Blood biochemistry: an increase in markers of inflammation and cholestasis (alkaline phosphatase, bilirubin) is frequently registered, along with an increase in AST and amylase enzymatic activity.
Instrumental visualization: The primary and most informative method is ultrasound examination (ultrasound). It allows the physician to visualize the presence of calculi, assess organ size and wall thickness, determine the consistency of contents, and identify pericholecystic inflammatory infiltrate.
At the same time, plain radiography of the abdomen in acute cholecystitis has low diagnostic value. The vast majority of gallstones are cholesterol-based and are radiolucent (rays pass right through them). Only 10–15% of calculi contain sufficient calcium to be visible on an X-ray.
Management tactics
When acute gallbladder inflammation is suspected, organizational measures boil down to a single rule: mandatory hospitalization of the patient in a surgical inpatient unit. The approach to treatment is strictly differentiated.
- Purulent and gangrenous forms: an absolute indication for surgical treatment. Cholecystectomy (removal of the affected organ) is performed.
- Catarrhal cholecystitis: allows for conservative therapy. The patient is prescribed strict bed rest. Diet plays a critical role: complete fasting is indicated for the first 2 days, followed by fractional nutrition (5–6 times a day) in minimal portions. The drug regimen includes the use of broad-spectrum antibiotics and antispasmodics to relieve the pain syndrome.
Briefly: answers to topical questions
What specific gallbladder signs are checked during palpation in a patient with suspected acute cholecystitis?
When acute cholecystitis is suspected, specific signs of gallbladder inflammation are checked during abdominal palpation. The main symptoms include:
- Murphy's sign — involuntary breath-holding (inspiratory arrest) during deep palpation in the right upper quadrant due to pain.
- Kehr's sign — tenderness upon palpation of the right upper quadrant directly during inspiration.
- Mussy-Georgievsky sign (phrenic nerve sign) — tenderness upon pressure at the point between the heads of the sternocleidomastoid muscle on the right due to radiation along the phrenic nerve.
- Ortner's sign — tenderness upon light percussion with the ulnar edge of the hand along the right costal margin when compared to the left side.
What are the absolute indications for emergency surgical treatment in acute cholecystitis?
Indications for emergency surgical treatment in acute cholecystitis include complicated and destructive forms of the disease:
- acute calculous cholecystitis complicated by gallbladder perforation and diffuse/generalized peritonitis;
- acute acalculous cholecystitis complicated by gallbladder perforation, diffuse, or generalized peritonitis;
- all forms of destructive cholecystitis complicated by localized or generalized peritonitis;
- in acute acalculous cholecystitis according to imaging data: gallbladder necrosis, emphysematous cholecystitis, or gallbladder perforation;
- in the absence of improvement within 24–48 hours after percutaneous microcholecystostomy in acute acalculous cholecystitis.
Emergency surgery is performed within the next 2–3 hours from the moment of diagnosis in cases specified for complicated cholecystitis with peritonitis.
What is the pathogenesis of pain syndrome development in calculous cholecystitis?
The pathogenesis of pain syndrome in calculous biliary tract disease is associated with the movement of a calculus and the resulting spasm of the smooth muscle of the gallbladder and ducts. Such biliary colic is characterized by a sudden onset, very intense pain with radiation upward, as well as nausea and vomiting that does not bring relief.
An additional mechanism of intense pain may be peritoneal irritation in pericholecystitis: the pain radiates upward to the right shoulder region and intensifies upon palpation of the right upper quadrant.
In chronic gallbladder inflammation, pain is described as aching or dull and is localized in the right upper quadrant.
Direction of pain in acute cholecystitis: "upward and backward" (right upper quadrant → right clavicle → right half of the neck → right scapula).
Class and exam questions
Why is ultrasound ordered instead of X-ray when gallbladder stones are suspected?
Most stones (up to 90%) consist of cholesterol, which is radiolucent and invisible on an X-ray. Ultrasound excellently visualizes any calculi and also shows the thickness of the inflamed gallbladder wall.
Does vomiting bring relief during a cholecystitis attack?
No. Unlike certain gastric diseases, nausea and vomiting in gallbladder inflammation are reflex in nature and do not improve the patient's well-being.
Is chronic cholecystitis linked to a prior episode of acute cholecystitis?
Chronic inflammation can indeed be the outcome of an acute attack. However, in practice, it much more frequently develops as a primary chronic process—independently and gradually.
What else to study on this topic
- Methodology for checking specific gallbladder signs during abdominal palpation.
- Features of the pathogenesis of cholesterol and calcified calculus formation.
- Mechanisms underlying the development of protective muscular guarding (défense musculaire).
- Differences in the clinical presentation of catarrhal, phlegmonous, and gangrenous cholecystitis.
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