Acute Cholecystitis: The Daily PANCE Blueprint

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Acute Cholecystitis: The Daily PANCE Blueprint

A 44-year-old obese woman presents with 6 hours of severe, constant right-upper-quadrant pain that began after a fatty meal and radiates to the right shoulder, with nausea and vomiting. Temperature is 38.3°C (101°F). On exam she has right-upper-quadrant tenderness and abruptly stops inspiration during deep palpation under the right costal margin (a positive Murphy sign). Which of the following is the most appropriate initial imaging study?

A. Right-upper-quadrant abdominal ultrasound
B. CT of the abdomen with contrast
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Magnetic resonance cholangiopancreatography (MRCP)
E. Endoscopic retrograde cholangiopancreatography (ERCP)

Answer and topic summary

The answer is A. Right-upper-quadrant abdominal ultrasound.

Postprandial RUQ pain radiating to the shoulder, fever, and a positive Murphy sign point to acute cholecystitis, and right-upper-quadrant ultrasound is the best initial imaging — fast, noninvasive, and able to show gallstones, gallbladder wall thickening (>3 mm), pericholecystic fluid, and a sonographic Murphy sign. A HIDA scan (cholescintigraphy) is the most sensitive confirmatory test but is reserved for when ultrasound is equivocal. CT is less sensitive for stones; MRCP and ERCP evaluate the bile ducts, and ERCP is therapeutic/invasive, not a first-line diagnostic.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Diseases of the Gallbladder ⇒ Acute and Chronic Cholecystitis

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