You've got some Gall(stones)

Acute cholecystitis is an obstruction problem that evolves from gallbladder distention to ischemia, inflammation, and sometimes gangrene or perforation. In right upper quadrant pain, ultrasound is first-line, CT is selective rather than routine, and symptom duration meaningfully changes operative difficulty.

Gallbladder pain and diagnosis

• Symptom duration signal: The surgeon cares how long the pain has been present because longer symptom duration usually means a harder operation and a more inflamed gallbladder, a practical distinction we get into in the episode.
• Biliary colic framing: Right upper quadrant pain with stones or sludge but no signs of cholecystitis or cholangitis is rarely an emergency, so other causes like peptic ulcer disease or pancreatic pathology still need attention.
• Exam and syndrome clues: Constant pain and a Murphy sign fit cholecystitis better than simple biliary colic, while jaundice points toward choledocholithiasis or cholangitis and epigastric pain radiating to the back suggests gallstone pancreatitis.
• Laboratory yield limits: No single lab rules out acute cholecystitis; WBC, CRP, and liver tests may rise, while lipase at three times normal supports gallstone pancreatitis rather than isolated gallbladder inflammation.
• Tokyo criteria anchor: The Tokyo Guidelines pair a local inflammatory sign with a systemic inflammatory marker, then require characteristic imaging for a definite diagnosis instead of relying on any one bedside finding.

Imaging and surgical pitfalls

• Ultrasound first choice: Ultrasound is the preferred initial test because it detects stones and inflammation directly, with findings like wall thickening, pericholecystic fluid, sludge, and a sonographic Murphy sign.
• CT good not great: CT can suggest cholecystitis but does not replace ultrasound for stones or grading inflammation; it becomes more useful when you suspect gangrenous or emphysematous disease, obstruction, or pancreatitis.
• Equivocal study next steps: A HIDA scan helps when ultrasound is equivocal, and MRCP or ERCP enters the picture when the common bile duct is poorly seen but suspicion for choledocholithiasis remains high.
• Operative timing reality: Immediate cholecystectomy is reserved for necrosis, perforation, or emphysematous cholecystitis; most acute cases can safely wait for daytime operative management after antibiotics and surgical evaluation.
• Post cholecystectomy bounceback: Biloma is a classic return visit after cholecystectomy, usually from a cystic duct clip failure or duct of Luschka leak, and CT is the diagnostic study. We cover the bounceback pattern in the chapter.

References: 

1. Wertz JR,et al. Comparing the Diagnostic Accuracy of Ultrasound and CT in Evaluating Acute Cholecystitis. AJR Am J Roentgenol. 2018;211(2):W92-W97. PMID: 29702020
2. Jain A, et al. History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Acad Emerg Med. 2017;24(3):281-297. PMID: 27862628
3. Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID: 29032636