Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy

Intravenous heparin therapy followed by embolectomy

Careful observation with serial abdominal examinations

Endoscopic retrograde cholangiopancreatography with papillotomy

Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show: Aspartate aminotransferase 142 U/L Alanine aminotransferase 86 U/L Alkaline phosphatase 153 U/L Total bilirubin 1.5 mg/dL Direct bilirubin 1.0 mg/dL Amylase 20 U/L Which of the following is the most likely diagnosis?

Acute cholecystitis (calculous)

A 45-year-old woman comes to the emergency department because of right upper abdominal pain and nausea that have become progressively worse since eating a large meal 8 hours ago. She has had intermittent pain similar to this before, but it has never lasted this long. She has a history of hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Current medications include metformin and enalapril. Her temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 130/80 mm Hg. The abdomen is soft, and bowel sounds are normal. The patient has sudden inspiratory arrest during right upper quadrant palpation. Laboratory studies show a leukocyte count of 13,000/mm3. Serum alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Imaging is most likely to show which of the following findings?

Dilated common bile duct with intrahepatic biliary dilatation

Enlargement of the pancreas with peripancreatic fluid

Decreased echogenicity of the liver

A 58-year-old woman comes to the emergency department because of a 2-day history of worsening upper abdominal pain. She reports nausea and vomiting, and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 132/85 mm Hg. Examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. Laboratory studies show: Hemoglobin 13 g/dL Leukocyte count 16,000/mm3 Serum Urea nitrogen 25 mg/dL Creatinine 2 mg/dL Alkaline phosphatase 432 U/L Alanine aminotransferase 196 U/L Aspartate transaminase 207 U/L Bilirubin Total 3.8 mg/dL Direct 2.7 mg/dL Lipase 82 U/L (N = 14–280) Ultrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder. The pancreas is not well visualized. Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole is begun. Twelve hours later, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangiopancreatography

Extracorporeal shock wave lithotripsy

Fourteen days after a laparoscopic cholecystectomy for cholelithiasis, a 45-year-old woman comes to the emergency department because of persistent episodic epigastric pain for 3 days. The pain radiates to her back, occurs randomly throughout the day, and is associated with nausea and vomiting. Each episode lasts 30 minutes to one hour. Antacids do not improve her symptoms. She has hypertension and fibromyalgia. She has smoked 1–2 packs of cigarettes daily for the past 10 years and drinks 4 cans of beer every week. She takes lisinopril and pregabalin. She appears uncomfortable. Her temperature is 37°C (98.6° F), pulse is 84/min, respirations are 14/min, and blood pressure is 127/85 mm Hg. Abdominal examination shows tenderness to palpation in the upper quadrants without rebound or guarding. Bowel sounds are normal. The incisions are clean, dry, and intact. Serum studies show: AST 80 U/L ALT 95 U/L Alkaline phosphatase 213 U/L Bilirubin, total 1.3 mg/dL Direct 0.7 mg/dL Amylase 52 U/L Abdominal ultrasonography shows dilation of the common bile duct and no gallstones. Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangiopancreatography

Counseling on alcohol cessation

Reassurance and follow-up in 4 weeks

A 45-year-old woman comes to the emergency department complaining of abdominal pain for the past day. The pain is situated in the right upper quadrant, colicky, 8/10, and radiates to the tip of the right shoulder with no aggravating or relieving factors. The pain is associated with nausea but no vomiting. She tried to take over-the-counter antacids which relieved her pain to a certain extent, but not entirely. She does not smoke cigarettes or drink alcohol. She has no past medical illness. Her father died of pancreatic cancer at the age of 75, and her mother has diabetes controlled with medications. Temperature is 38°C (100.4°F), blood pressure is 125/89 mm Hg, pulse is 104/min, respiratory rate is 20/min, and BMI is 29 kg/m2. On abdominal examination, her abdomen is tender to shallow and deep palpation of the right upper quadrant. Laboratory test Complete blood count Hemoglobin 13 g/dL WBC 15,500/mm3 Platelets 145,000/mm3 Basic metabolic panel Serum Na+ 137 mEq/L Serum K+ 3.6 mEq/L Serum Cl- 95 mEq/L Serum HCO3- 25 mEq/L BUN 10 mg/dL Serum creatinine 0.8 mg/dL Liver function test Total bilirubin 1.3 mg/dL AST 52 U/L ALT 60 U/L Ultrasonography of the abdomen shows normal findings. What is the best next step in management of this patient?

Reassurance and close follow up

A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Laparoscopic removal of ovarian cysts

Intramuscular ceftriaxone followed by cephalexin

Acute cholecystitis for USMLE Step 3: High-Yield Surgery Lessons

Pathophysiology & Etiology - Gallbladder's Grudge

Calculous Cholecystitis (>90%): A gallstone obstructs the cystic duct, leading to inflammation. This is the most common cause.
Acalculous Cholecystitis (5-10%): Gallbladder inflammation without stones. Associated with biliary stasis in critically ill patients (e.g., sepsis, TPN, major trauma).

⭐ Acalculous cholecystitis carries a higher risk of gangrene, perforation, and mortality compared to calculous cholecystitis.

Clinical Presentation - Biliary Bellyache

Location: RUQ or epigastric pain; constant & severe.
Radiation: Right shoulder or scapula (Boas' sign).
Onset: Often postprandial, especially after fatty meals.
Associated: Fever, nausea, vomiting, anorexia.

Physical Exam:

Positive Murphy's Sign: Inspiratory arrest on deep RUQ palpation.
Fever (usually low-grade).
Palpable, tender gallbladder in ~33% of cases.

Acute Cholecystitis: Symptoms and Murphy's Sign

⭐ Acalculous cholecystitis presents with similar signs but in critically ill patients (e.g., on TPN, post-op, trauma).

Diagnosis - Catching the Culprit

Initial Labs:
- CBC: Leukocytosis with a left shift (↑ WBC).
- LFTs: May show ↑ Alk Phos, ↑ Bilirubin.
- Amylase/Lipase: To rule out pancreatitis.
Imaging Gold Standard:
- First & Best Test: Right Upper Quadrant (RUQ) Ultrasound.
  - Findings: Gallbladder wall thickening (>3 mm), pericholecystic fluid, gallstones, sonographic Murphy's sign.
- Most Accurate Test: HIDA (Hepatobiliary Iminodiacetic Acid) Scan.
  - Indicated if ultrasound is equivocal.
  - Positive test: Non-visualization of the gallbladder.

Gallbladder and surrounding organs

⭐ Acalculous Cholecystitis: Suspect in critically ill patients (e.g., prolonged TPN, trauma, burns) with unexplained fever and RUQ pain. Diagnosis often requires HIDA scan as ultrasound may be non-specific.

Management - Gallbladder's Eviction

Initial Stabilization: NPO, IV fluids, analgesia, and IV antibiotics (e.g., Ceftriaxone + Metronidazole) to cover gram-negatives and anaerobes.
Definitive Treatment: Laparoscopic cholecystectomy is the gold standard.

⭐ Early cholecystectomy (within 72 hours of symptom onset) is crucial. It leads to shorter hospital stays and reduced risk of complications compared to delayed surgery.

Complications - When Things Go South

Gangrenous Cholecystitis: Most common severe complication, especially in elderly or diabetic patients. Features necrosis and ischemia of the gallbladder wall.
Perforation: May be localized (forming a pericholecystic abscess) or free, leading to generalized peritonitis.
Emphysematous Cholecystitis: A surgical emergency caused by gas-forming organisms (e.g., Clostridium). More common in diabetic men; carries high mortality.
Cholecystoenteric Fistula: An abnormal connection to the bowel.

Abdominal X-ray: Rigler's triad in gallstone ileus

⭐ Gallstone Ileus: A classic complication where a large stone passes through a fistula and obstructs the ileocecal valve, causing Rigler's triad: pneumobilia, small bowel obstruction, and an ectopic gallstone.

High‑Yield Points - ⚡ Biggest Takeaways

Acute cholecystitis is most commonly caused by a gallstone obstructing the cystic duct.

Classic presentation includes RUQ pain (often radiating to the right scapula), fever, and a positive Murphy's sign.

The best initial diagnostic test is an ultrasound; the most accurate is a HIDA scan.

Expect leukocytosis with a left shift; serum aminotransferases and amylase can be mildly elevated.

Treatment is supportive care followed by laparoscopic cholecystectomy.

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