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 diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
Mild jaundice (serum bilirubin <60 micromol/L) can be the presenting sign in severe acute cholecystitis. It is caused by inflammation and oedema 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's syndrome (impaction of a gallstone in Hartmann's pouch causing obstruction). Sepsis may develop if there is superimposed bacterial infection. Acute cholecystitis can occur without gallstones (acalculous cholecystitis). This is more common in critically ill patients and those >65 years of age.
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