Clinical Scenarios in Surgery™

Right Upper Quadrant Pain Due to Acute Cholecystitis

Scenario overview

A 35-year-old woman presents with persistent right upper quadrant abdominal pain, nausea, vomiting, and a low-grade fever. Her evaluation demonstrates gallstones and an inflamed gallbladder consistent with acute calculous cholecystitis.

Primary diagnosis: Acute calculous cholecystitis
Probable severity: Tokyo Grade I—mild
Expected treatment: Early laparoscopic cholecystectomy during the same hospitalization.

  • Patient: Sarah M., 35-year-old female
    Location: Emergency department
    Chief complaint: “I have severe pain under my right ribs that will not go away.”

    History of present illness

    Sarah reports:

    • Constant right upper quadrant pain beginning approximately 12 hours ago

    • Pain radiating toward the right shoulder blade

    • Increasing pain after eating a fatty meal

    • Nausea and two episodes of vomiting

    • Reduced appetite

    • Temperature of 100.6°F (38.1°C)

    • Several previous episodes of milder post-meal pain that resolved within two hours

    • No jaundice, dark urine, pale stools, chest pain, or shortness of breath

    Unlike her earlier episodes—more consistent with biliary colic—this pain has persisted and is associated with fever and localized inflammation.

    Relevant history

    • Obesity: BMI 32 kg/m²

    • Hyperlipidemia

    • Gastroesophageal reflux disease

    • Previous cesarean section

    • No known liver disease

    • No anticoagulant use

    • No medication allergies

    • Pregnancy status unknown on arrival

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