Case history
Case history
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhea. Three months ago she developed intermittent, sharp RUQ pains. On physical exam she has a temperature of 100.4°F (38ºC), moderate RUQ tenderness on palpation, but no evidence of jaundice.
Other presentations
Mild jaundice (serum bilirubin <60 micromol/L) can be the presenting sign in severe acute cholecystitis. It is caused by inflammation and edema around the biliary tract, as well as direct pressure from the distended gallbladder. A serum bilirubin >60 micromol/L suggests choledocholithiasis (gallstone in the common bile duct) or Mirizzi syndrome (impaction of a gallstone in Hartmann pouch causing obstruction).[7] Septicemia may develop if there is superimposed bacterial infection.[7] Acute cholecystitis can occur without gallstones (acalculous cholecystitis). This is more common in critically ill patients and those ages >65 years.
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