Cholecystitis & Cholelithiasis

That sharp right upper quadrant pain after a fatty meal isn't just indigestion — a positive Murphy's sign tells you the gallbladder is inflamed, and the next few hours determine surgical timing.

Cholelithiasis refers to gallstones in the gallbladder; cholecystitis is inflammation of the gallbladder wall, most often caused by a stone obstructing the cystic duct. The classic presentation is sudden, severe right upper quadrant (RUQ) or epigastric pain radiating to the right scapula, triggered by high-fat meals. Pain typically lasts longer than 30 minutes and is accompanied by nausea, vomiting, and low-grade fever. Murphy's sign — inspiratory arrest during palpation of the RUQ — is the hallmark physical finding. Risk factors follow the "5 Fs": Female, Forty, Fat, Fertile, Fair, though men and younger patients can be affected. Key labs include elevated WBC (infection/inflammation), elevated alkaline phosphatase and direct bilirubin (if a stone obstructs the common bile duct), and possibly elevated amylase if the pancreatic duct is involved. Ultrasound is the first-line diagnostic study. Definitive treatment is laparoscopic cholecystectomy. Preoperatively, the patient is NPO, given IV fluids, antiemetics, and analgesics. A T-tube may be placed in the common bile duct during open cholecystectomy to drain bile; you monitor output color (initially dark green, lightening over days), keep the bag below the insertion site, and never clamp without an order.

Key Distinctions

Don't confuse cholecystitis pain (RUQ radiating to right scapula, worse after fatty foods) with pancreatitis pain (epigastric boring through to the back, worse when supine). Students mix up cholelithiasis (stones present, may be asymptomatic) with cholecystitis (active inflammation — fever, elevated WBC, positive Murphy's sign). A T-tube is placed in the common bile duct to drain bile externally; it is NOT the same as a Jackson-Pratt drain, which collects serous fluid.

Clinical Pearl

Think "5 Fs and a scapula": Female, Forty, Fat, Fertile, Fair — with pain aiming straight at the right shoulder blade. That radiation pattern is your clinical giveaway.