I. Key Diagnostic Points

I. Key Diagnostic Points

(1) Clinical Symptoms

1. Acute Cholecystitis The main symptom of an acute cholecystitis attack is upper abdominal pain, often triggered by high-fat diets, alcohol consumption, emotional stress, and other factors. Initially, it manifests as bloating and discomfort in the upper abdomen, usually due to poor bile flow and increased pressure inside the gallbladder. If the obstruction persists and worsens, the gallbladder undergoes strong spasmodic contractions, and the bloating quickly turns into paroxysmal colic, with pain radiating to the right shoulder or the area under the right scapula. Another characteristic of gallstone-related colic is that the pain often occurs at night, due to body position: when lying flat or on the side, stones floating in the bile may suddenly block the gallbladder neck, causing strong contractions of the gallbladder. If bacterial infection occurs, the patient's body temperature can rise to 40°C, accompanied by chills. As the infection is controlled, these symptoms gradually disappear. In addition, sometimes gallstone colic caused by improper body position can even disappear when the position changes, because the stone blocking the gallbladder neck leaves the neck as the position changes, and once the obstruction is lifted, the colic disappears. Clinically, we often encounter patients who rush to the hospital in the middle of the night, only to find that their abdominal pain has disappeared—likely due to the reasons mentioned above. Approximately one-quarter of patients with acute cholecystitis develop jaundice, but it is usually mild and resolves on its own after the inflammation is controlled. Vomiting is also a common symptom of acute cholecystitis and cholelithiasis, generally alleviated in the short term after anti-infection and spasmolytic treatment. If gallstones pass through the gallbladder duct into the common bile duct and stimulate the sphincter of Oddi, vomiting becomes more frequent and severe.

2. Chronic Cholecystitis The clinical presentation of chronic cholecystitis during acute attacks is similar to that of acute cholecystitis, with the main cause being obstruction of the gallbladder neck due to stones. During the quiescent phase of chronic cholecystitis, symptoms are often atypical: when the gallbladder duct is not blocked, patients may feel no particular discomfort, or occasionally experience vague pain below the xiphoid process and mild gastrointestinal symptoms, such as postprandial fullness, belching, and hiccups; they may also experience loss of appetite, aversion to fatty foods, indigestion, and constipation. The dull pain in the right upper abdomen often radiates to the right shoulder.

(2) Physical Signs

In the early stages of acute cholecystitis, there may be obvious tenderness in the right upper abdomen; in severe cases, there may be rebound tenderness and abdominal muscle tension. When pressing deeply on the gallbladder area while the patient takes a deep breath, there is a sensation of tenderness, known as a positive "Murphy's sign." A swollen gallbladder can also often be palpated. In chronic cholecystitis, physical signs are often less obvious, or there may be localized deep tenderness in the gallbladder area. In cases of gallbladder hydrops, a mass that moves up and down with breathing can be felt in the right upper abdomen.

(3) Auxiliary Examinations

(1) Laboratory Tests: Acute cholecystitis may show elevated white blood cell and neutrophil counts, and liver function tests may reveal elevated transaminases along with increased serum bilirubin.

(2) Ultrasound Examination: Can reveal an enlarged gallbladder and thickened gallbladder wall, gallstones inside the gallbladder, and inflammatory exudation around the gallbladder—this is the most commonly used diagnostic method in clinical practice.

(3) Cholecystography: Used for chronic cholecystitis, in addition to assessing the shape, size, and presence of stones in the gallbladder, it can also evaluate the gallbladder's contractile function.

(4) ERCP (Endoscopic Retrograde Cholangiopancreatography): Can also be used for patients with chronic cholecystitis or concurrent bile duct lesions.