These days medical students are just flooded with a huge amount of information –different description of diseases, fresher and fresher publications – available online. It is really difficult to pick the clinically relevant data, especially when you do not have those years of practice behind your back. In our blog series You will find short and straightforward lists of clinical signs, symptoms which are the most typical and pathognomonic in certain diseases.
Are you familiar with The Awkward Yeti? You should be because this comic makes You feel genuinely compassionate with poor Gallbladder. He is just making stones and nobody appreciates it :( Seriously, however, having gallstones (and also other conditions) can lead to the severe inflammation of the gallbladder, called cholecystitis. To avoid its complications and recognize it in time, let’s go through the seven most typical symptoms of cholecystitis!
1. Epigastric and right upper quadrant (RUQ) pain
Why? The obstruction of the cystic duct by (most commonly) gallstones is just one of the many reasons standing behind cholecystitis. In developing countries, the infectious origin is also a major cause. These all lead to the inflammation of the gallbladder. The release of proinflammatory cytokines is the primary cause of the occurring pain, which initially appears in the epigastrium, later in the right upper quadrant. It is severe, dull, lasts for hours or days and may radiate to the right scapular region or back.
2. Nausea, vomiting
Why? The severe visceral pain, the visceral inflammation and the possible elevation of the different components of the bile in the serum can lead to severe nausea and vomiting.
3. Low-grade fever
Why? It is the consequence of the inflammatory response of the healthy human body. In elderly patients, fever may be absent. Patients with acalculous cholecystitis may present with fever and sepsis alone, without any other physical signs of acute cholecystitis.
4. Positive Murphy-sign, palpable gallbladder
Why? The distended gallbladder is physically bigger, so it can be palpable. Ask your patient to breathe out. Place your hand below the costal margin on the right side, at the mid-clavicular line. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers), the test is considered positive.
5. 5-F rule :)
Why? The 5-F rule refers to the major risk factors for the development of cholelithiasis in the event of upper abdominal pain. These are:
More common among Caucasians and Northern Europeans
BMI > 30
One or more children
Age ⋝ 40
6. Elevated lab parameters
Why? These enzymes and molecules all can be found in the biliary tract system. If the common bile tract is closed, the level of these particles will increase due to the congestion of the bile.
Its elevation manifests in conjugated hyperbilirubinemia that can cause jaundice in 15% of patients.
This membrane-bound enzyme is localized to the bile canalicular pole of hepatocytes and markedly elevated in biliary obstruction.
Gamma-glutamyl transpeptidase (GGT)
GGT is present in the cell membrane of bile tracts.
The last one is an “odd-one-out” but at the same time, it may be the most obvious one. The elevation of white blood cells in the serum appears very often with cholecystitis. The famous triad of this disease is RUQ-tenderness, fever and leukocytosis!
Why? Based on the recommendations of the American College of Radiology, ultrasonography is the preferred initial imaging test for the diagnosis of cholecystitis. Here are the most typical findings:
Gallbladder distention (diameter >4 cm, length >10 cm)
Gallbladder wall thickening (>2-4 mm)
Pericholecystic fluid from perforation or exudate
Ultrasonographic Murphy sign
The presence of gallstones helps to confirm the diagnosis - indirect sign of gallstones: dilated common bile duct or dilated intrahepatic bile ducts of the biliary tree.
After learning the basics, test your knowledge in practice by solving cases in InSimu Patient app! You can download it for iOS or Android.