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.