🪨 Acute Cholecystitis Diagnostic Pathway Simulator

Right Upper Quadrant Pain Onset

Steady RUQ pain follows a fatty meal.

• 90%+: RUQ pain in confirmed cases (near-universal symptom)
• Fatty meal: Common trigger (gallbladder contraction)
• Right scapula: Pain radiation (referred pattern)
• 6–12 h: Typical time to presentation (after symptom onset)

Colic vs. cholecystitis

Colic resolves fast; cholecystitis pain persists past six hours.

Pain mechanism

Cystic duct obstruction distends the inflamed gallbladder wall.

Associated symptoms

Nausea, vomiting, and low fever often accompany the pain.

Murphy's Sign Elicited

Deep RUQ palpation during inspiration is tested.

• 65%: Sensitivity (pooled clinical studies)
• 87%: Specificity (pooled clinical studies)
• Direct contact: Mechanism (inflamed gallbladder meets hand)
• Deep breath: Test position (during RUQ pressure)

Testing technique

Examiner presses the RUQ as the patient inhales deeply.

Positive response

Patient halts inspiration abruptly from sharp local pain.

Diagnostic value

Paired with imaging, it raises overall diagnostic likelihood.

Leukocytosis Confirms Inflammation

Elevated white cell count signals active infection.

• 4.5–11k: Normal WBC range (cells / µL)
• 12–15k: Typical cholecystitis WBC (cells / µL)
• ↑ Neutrophils: Left shift (immature forms appear)
• Common: CRP elevation (frequent co-finding)

Why WBC rises

Bacterial invasion of the gallbladder wall triggers an immune response.

Left shift

Immature neutrophils appear as infection intensifies.

Limitations

Normal WBC does not exclude mild cholecystitis.

Ultrasound Reveals Structural Change

Sonography visualizes the gallbladder wall and fluid.

• >3 mm: Wall thickness cutoff (abnormal threshold)
• Anechoic rim: Pericholecystic fluid (around the gallbladder)
• Probe tenderness: Sonographic Murphy sign (direct correlate)
• 81–88%: Ultrasound sensitivity (for acute cholecystitis)

Wall thickening

Edema thickens the gallbladder wall beyond three millimeters.

Pericholecystic fluid

Fluid collects around an acutely inflamed gallbladder.

Sonographic Murphy sign

Probe pressure reproducing pain strengthens the diagnosis.

Acute Cholecystitis Confirmed

Clinical, lab, and imaging findings converge.

• 3 categories: Tokyo Guidelines (local + systemic + imaging)
• 90%+: Diagnostic confidence achieved (combined criteria)
• Surgical consult: Next step (for cholecystectomy)
• <72 h: Preferred timing (early cholecystectomy)

Tokyo Guidelines

Local signs, systemic signs, and imaging together confirm diagnosis.

Treatment pathway

Laparoscopic cholecystectomy is the definitive treatment.

Prognosis

Early surgery lowers complication rates versus delayed surgery.