Your next patient has had upper right tummy pain for 1 day. Here's how the acute cholecystitis case unfolds and what to pick up on the way.

An acute cholecystitis case can be missed when constant right upper quadrant pain is mistaken for another brief bout of biliary colic. Here, the pain is severe for about a day, started after a fatty meal, radiates to the right scapula, and the patient feels feverish, with past short attacks that settled within hours, known gallstones, and no jaundice or colour change in urine or stools.

This page walks through how this presentation unfolds: what to pick up in the history, bedside findings such as a possible Murphy's sign, and the tests that help separate inflammation from simple colic. We’ll cover checking inflammatory markers, white cell count and CRP, liver function tests for an obstructive pattern that might suggest a common bile duct stone and prompt MRCP or ERCP, and amylase or lipase to exclude gallstone pancreatitis.

How the case presents

Your next patient has had upper right tummy pain for 1 day. In their own words: "Severe pain in the upper right side of the tummy for about a day."

Observations on arrival:

Observation	On arrival
Heart rate	96 beats per minute
Blood pressure	132/82 mmHg
Respiratory rate	18 breaths per minute
Oxygen saturation	98%
Temperature	38.1 °C

What to pick up in the history

These are the findings the case is built around. Each one moves you towards or away from acute cholecystitis, and the scorecard checks whether you found it.

Constant severe right upper quadrant pain for a day: pain persisting beyond hours marks inflammation of the gallbladder rather than transient biliary colic.
Came on after a fatty meal, radiates to the scapula: fatty-food trigger with referred right shoulder-tip pain is the classic biliary pattern.
Feels feverish.
Previous brief attacks that settled within hours: establishes a background of biliary colic and shows this attack has crossed into inflammation.
Known gallstones on a previous scan: confirms the substrate, making cystic duct obstruction the leading mechanism.
Not jaundiced, urine and stools normal colour: absent obstructive jaundice argues against a common bile duct stone and against cholangitis.
No rigors, swinging fever or confusion.

Red flags you must not miss

The case marks these as must-elicit. They only come out if you ask.

Not jaundiced, urine and stools normal colour.
No rigors, swinging fever or confusion.

Investigations and what they showed

Full blood count: Raised white cell count (neutrophilia). Why it helps: supports acute inflammation/infection of the gallbladder and distinguishes cholecystitis from uncomplicated biliary colic (which lacks the inflammatory response).
C-reactive protein: Raised. Why it helps: reflects the inflammatory response of cholecystitis and helps gauge severity.
Liver function tests: Mildly deranged; the bilirubin/ALP are not markedly raised (a markedly obstructive picture would suggest a common-bile-duct stone/cholangitis).
Ultrasound abdomen: The first-line investigation, it confirms gallstones and the features of acute cholecystitis, and checks the bile duct calibre (a dilated duct suggests a CBD stone).
Inspect the tongue: A dry, heavily coated and furred tongue. Why it helps: he has been vomiting, febrile and off food for a day.
Inspect the patient (general appearance): 1 degrees, flushed, warm, with a damp brow, lying still rather than restless. Why it helps: the fever and the systemic upset are what separate acute cholecystitis from simple biliary colic, which produces severe pain but no inflammatory response.
Inspect the abdomen: The right upper quadrant is held rigid and does not move freely with respiration; the rest of the abdomen moves normally. There is no distension and no visible scar. Why it helps: localised guarding over an inflamed gallbladder is the visible counterpart of Murphy's sign. The absence of generalised rigidity argues against perforation, and the absence of distension against obstruction.
Inspect the patient's posture and position: He lies very still on his back, reluctant to move or take a deep breath, and winces when asked to shift up the bed. Why it helps: peritoneal inflammation makes movement hurt, so the patient keeps still, the opposite of the writhing, restless patient with true colic such as renal or intestinal colic. Watching how a patient with abdominal pain lies is diagnostic before you lay a hand on them.
Inspect the patient's body habitus: A middle-aged man of heavy build with central adiposity.
Inspect the vomitus: Bilious non-faeculent vomit fits reflex vomiting from an inflamed gallbladder. Faeculent vomit would point to distal bowel obstruction, and haematemesis to an upper GI cause entirely.

Imaging findings

MRCP: Reserved for a dilated bile duct / deranged LFTs, looks for a common-bile-duct stone (choledocholithiasis).
CT abdomen and pelvis: Used if the diagnosis is unclear or complications (empyema, gangrene, perforation) are suspected.
X-ray abdomen: May show a radio-opaque gallstone or a calcified 'porcelain' gallbladder; most gallstones are radiolucent so a normal film does not exclude disease.
ECG (bedside 12-lead): Normal 12 lead ECG sinus rhythm.

Why the diagnosis is acute cholecystitis

The decisive diagnosis is acute cholecystitis, inflammation of the gallbladder (usually from a stone obstructing the cystic duct). The clues are constant (not brief) right-upper-quadrant pain lasting hours, radiating to the right shoulder, precipitated by fatty food, with nausea, fever and a positive murphy's SIGN, plus a raised white cell count/CRP. 'Biliary colic' is the correct umbrella but less specific, colic is transient pain from a stone without inflammation/fever and settles within hours; the persistent pain, fever and inflammatory markers mark this as cholecystitis.

Acute cholecystitis at a glance

What it is

Acute cholecystitis is inflammation of the gallbladder, in over 90% of cases from a gallstone obstructing the cystic duct. It causes constant right-upper-quadrant pain lasting hours, radiating to the right shoulder, often after fatty food, with nausea, fever and a positive Murphy's sign.

Pathogenesis

A stone impacts the cystic duct, trapping bile in the gallbladder. Rising pressure and bile stasis irritate and inflame the gallbladder wall, which thickens and becomes oedematous; secondary bacterial infection often follows. This inflammatory process, not just transient stone impaction, is what distinguishes cholecystitis from simple biliary colic, and explains the fever and raised inflammatory markers that colic lacks.

Who it affects

Gallstones affect 10 to 15% of adults in developed countries, more often women, and risk rises with obesity, pregnancy, rapid weight loss, diabetes and the oral contraceptive pill. Only a minority of stone-carriers develop cholecystitis, usually when a stone impacts the cystic duct.

How serious it is

Coexisting common-bile-duct obstruction or ascending cholangitis significantly raises the stakes and needs urgent recognition.

Causes and risk factors

A gallstone obstructing the cystic duct is the cause in the great majority of cases; acalculous cholecystitis (without stones) occurs in critically unwell patients. Risk factors mirror those for gallstones: female sex, obesity, pregnancy, rapid weight loss and diabetes.

Investigations and lab tests

LFTs are checked: significantly deranged obstructive LFTs suggest a common-bile-duct stone needing MRCP or ERCP. Amylase/lipase excludes gallstone pancreatitis, and Charcot's triad (pain, fever, jaundice) should prompt urgent evaluation for cholangitis.

At a glance: Suggests CBD stone: deranged obstructive LFTs. Excludes pancreatitis: amylase/lipase.

Teaching points

Acute cholecystitis is inflammation of the gallbladder (usually a stone in the cystic duct), constant right-upper-quadrant pain for hours, radiating to the right shoulder, after fatty food, with nausea, fever and a positive Murphy's sign.
It differs from biliary colic, which is transient pain without fever/inflammation that settles within hours; the fever and raised white-cell count/CRP mark cholecystitis.
Check LFTs, significantly deranged obstructive LFTs suggest a common-bile-duct stone (choledocholithiasis) needing MRCP/ERCP.
Check amylase/lipase to exclude gallstone pancreatitis.
Watch for complications: empyema, gangrenous or perforated gallbladder, and Mirizzi syndrome.

Practise a similar case

Reading about constant right upper quadrant pain after a fatty meal is one thing, but catching that detail while the clock is ticking and the story meanders is different. When you are the one asking, you have to tease out radiation to the shoulder and brief prior episodes without leading. Now try taking a history from another simulated patient.

Here's one from the same specialty, with the diagnosis left for you to find. Your next patient is a 24-year-old man with belly pain and a fever since yesterday. Take this patient's history in Diagnosica. It's free to start, no card needed.

Acute cholecystitis case presentation: history, findings and tests