Acute Cholecystitis Presenting With Atypical Radiologic or Laboratory Findings: A Case Report

Acute cholecystitis is the most common presentation of gallbladder (GB) disease. It has an incidence of around 200,000 cases a year in the United States (US) and affects approximately 20 million individuals in the US. In most cases, it presents with a history of symptomatic gallstones. Initial management includes intravenous hydration and antibiotics, bowel rest, and analgesia. Complicated cases are typically resolved with surgery (laparoscopic cholecystectomy). The pathogenesis of acute cholecystitis is most often explained by obstruction of the cystic duct. Research has shown that there are more contributing factors than just obstruction alone. We present a case of a 38-year-old Hispanic woman who came to our emergency department with a chief complaint of the anterior chest wall and epigastric pain. Physical examination was remarkable for epigastric tenderness and negative Murphy's sign. She had no fever. Cardiac troponins and electrocardiogram (EKG) were negative. Initial labs showed no sign of infection with white blood cell (WBC) count within the normal range, and only mildly elevated aspartate aminotransferase (AST), alanine transaminase (ALT), and total bilirubin. Follow-up abdominal computerized tomography (CT) scan without contrast and right upper quadrant (RUQ) abdominal ultrasound showed cholelithiasis without evidence of cholecystitis. An hepatobiliary iminodiacetic acid (HIDA) scan on day three of admission revealed an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy with an intraoperative cholangiogram. The surgery was uneventful; it was remarkable for a very distended, inflamed, and edematous GB, which had to be decompressed with a lap needle for removal. It is evident that acute cholecystitis may not always present with the classic diagnostic criteria, including laboratory results (leukocytosis, elevated C-reactive protein) and physical exam findings (fever, RUQ pain, and + Murphy’s sign). However, a thorough work-up can be just as effective in diagnosis.