Uh, can you give me some case studies for, uh, cholelithiasis, uh, acute chronic cholecystitis and chronic cholecystitis for, uh... For testing me, like I need to test myself for how much I have understood and how much I'm able to diagnose. So can you give me some case studies for this?

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Here are three clinical case studies for self-testing. Each case is followed by a set of questions. Try to answer them before scrolling down to the answers section.

Case 1 - Cholelithiasis (Symptomatic Gallstones / Biliary Pain)

Presentation

A 42-year-old obese woman (BMI 34) presents to the outpatient clinic with episodic upper abdominal pain over the last 4 months. She describes the pain as a steady ache in the epigastrium that sometimes radiates to the right shoulder and scapula. Each episode lasts about 1-2 hours, then slowly resolves on its own. The pain often comes on in the evening, sometimes after a fatty meal, but often with no clear trigger. She reports nausea and mild sweating during attacks but no vomiting. She has had 3 pregnancies. She is not on any medications.

Vitals: T 37.1°C, HR 76, BP 124/82, SpO2 99%

Physical exam: Mild tenderness on deep palpation of the RUQ between attacks. No guarding, no rigidity. No jaundice. Murphy's sign negative at the time of examination.

Labs:

WBC: 7,200/mm³ (normal)
LFTs: normal (ALP, AST, ALT, bilirubin all within range)
Amylase/lipase: normal

Investigations ordered: Abdominal ultrasound

Test Yourself

What is the most likely diagnosis? What are the key features pointing to it?
What risk factors does this patient have? Name the classic mnemonic.
Describe what you expect to see on ultrasound.
The pain is "steady," not crampy. Why is the term "biliary colic" a misnomer?
The patient asks: "My doctor said I might not need surgery if my only symptoms are bloating and gas. Why?" How would you explain this?
What is the first-line definitive management?
What serious complications can arise if this is left untreated?

Answers - Case 1

1. Diagnosis: Symptomatic cholelithiasis (biliary pain). Key features: obese multiparous woman, episodic steady RUQ/epigastric pain lasting 1-2 hours, radiation to right shoulder/scapula, associated nausea, normal labs between attacks, no fever/leukocytosis.

2. Risk factors: The classic "5 Fs" - Fat, Fertile (multiparous), Forty, Female, Fair (Caucasian). This patient has obesity, multiparity, age 40s, and female sex.

3. Ultrasound findings: Echogenic foci (hyperechoic structures) within the gallbladder lumen that cast acoustic shadowing, and move with change in patient position (gravity-dependent). Gallbladder wall is not thickened, no pericholecystic fluid.

4. Misnomer: The term "biliary colic" implies an intermittent/crampy pain (like intestinal colic). In reality, biliary pain is steady, rises over 15-60 minutes, plateaus for 1+ hour, then slowly resolves. It is not truly colicky. - Sleisenger & Fordtran, p.1241

5. Nonspecific symptoms: Bloating, flatulence, and dyspepsia are NOT caused by gallstones themselves - these symptoms occur with equal frequency in people without gallstones. Cholecystectomy will not relieve them. Only true biliary-type episodic pain is an indication for surgery. - Sleisenger & Fordtran

6. Management: Elective laparoscopic cholecystectomy. Medical dissolution (ursodeoxycholic acid) is rarely used and only for small cholesterol stones in non-surgical candidates.

7. Complications: Acute cholecystitis, choledocholithiasis (CBD stones), ascending cholangitis, gallstone pancreatitis, gallstone ileus, and increased risk of gallbladder carcinoma.

Case 2 - Acute Cholecystitis

Presentation

A 55-year-old man with known gallstones (diagnosed incidentally 2 years ago) presents to the Emergency Department with severe, constant right upper quadrant pain for the past 14 hours. The pain started after a large meal, radiated to the right shoulder, and has not resolved unlike his prior episodes. He has had fever, chills, nausea, and two episodes of vomiting. He has no jaundice.

Vitals: T 38.7°C, HR 104, BP 130/88, RR 18, SpO2 97%

Physical exam:

Right subcostal region is tender and rigid
Murphy's sign: positive (patient catches their breath on deep RUQ palpation during inspiration)
No palpable gallbladder mass
No jaundice, no scleral icterus

Labs:

WBC: 14,800/mm³ (elevated, with neutrophilia)
Total bilirubin: 1.3 mg/dL (borderline)
ALP mildly elevated; ALT/AST mildly elevated
Amylase/lipase: normal
CRP: markedly elevated

Ultrasound: Gallstones present. Gallbladder wall thickening (>4 mm). Pericholecystic fluid. Sonographic Murphy sign positive.

Test Yourself

What is the diagnosis? What are the criteria that confirm it?
What is the pathophysiology of acute calculous cholecystitis?
What is Murphy's sign and what is its significance?
The WBC is 14,800. When should you be alarmed and suspect empyema or perforation?
Why are bilirubin and liver enzymes slightly elevated here? Does this mean CBD stones are present?
What are the possible complications if not treated promptly?
What is the definitive treatment and what is the optimal timing?
Suggest the differential diagnoses you must rule out.

Answers - Case 2

1. Diagnosis: Acute calculous cholecystitis. Confirmed by: RUQ pain >6 hours duration (distinguishes from simple biliary pain), fever, leukocytosis, positive Murphy's sign, and ultrasound showing gallstones + wall thickening + pericholecystic fluid + sonographic Murphy sign.

2. Pathophysiology: A gallstone obstructs the cystic duct or gallbladder neck → bile outflow obstruction → phospholipases hydrolyze biliary lecithin to toxic lysolecithin → disruption of the protective mucous layer → bile salts exert detergent action on mucosa → prostaglandins released → mural inflammation → distension → ischemia → all occurring WITHOUT bacterial infection initially (bacteria may be superimposed later). - Robbins Pathology, p.633

3. Murphy's sign: The examiner places a hand under the right costal margin while the patient takes a deep breath. The inflamed gallbladder descends and strikes the examiner's fingers, causing the patient to suddenly stop inspiring (catch their breath) due to pain. Sonographic Murphy sign (tenderness directly under the ultrasound probe over the gallbladder) has a positive predictive value >90% for acute cholecystitis when gallstones are also present. - Sleisenger & Fordtran, p.1243

4. Alarm threshold: WBC >15,000/mm³, especially combined with worsening pain, high fever (>38.9°C / >102°F), and chills - raise suspicion for empyema (pus-filled gallbladder) or perforation requiring urgent surgical intervention. - Sleisenger & Fordtran, p.1243

5. Mild bilirubin/LFT elevation: Mild elevation is common due to local inflammation and edema compressing intrahepatic bile ducts. It does NOT necessarily mean CBD stones (choledocholithiasis). However, if bilirubin is significantly elevated (>3 mg/dL) with dilated CBD on US, CBD stones must be actively excluded with MRCP or EUS.

6. Complications:

Empyema of the gallbladder
Gangrenous cholecystitis
Perforation → local abscess or diffuse peritonitis
Cholecystoenteric fistula → gallstone ileus
Bacterial superinfection → cholangitis, sepsis
Robbins Pathology

7. Treatment: Laparoscopic cholecystectomy. Early surgery (within 3 days of presentation) is preferred over delayed surgery (6-8 weeks later) based on multiple prospective RCTs - it reduces total hospital stay and avoids risk of recurrent attacks while waiting. - Sleisenger & Fordtran, p.1241

8. Differential diagnoses: Acute appendicitis (if high-lying appendix), acute pancreatitis (check amylase/lipase), peptic ulcer perforation, right-sided pyelonephritis/renal colic, acute hepatitis, hepatic abscess, right lower lobe pneumonia, gonococcal/chlamydial perihepatitis (Fitz-Hugh-Curtis syndrome). - Sleisenger & Fordtran, p.1243

Case 3 - Chronic Cholecystitis

Presentation

A 48-year-old woman presents with a 2-year history of recurrent, dull right upper quadrant discomfort and occasional episodes of more intense RUQ/epigastric pain, each lasting 30-90 minutes. She reports the episodes occur about once or twice a month. Between episodes, she feels fine. She also complains of flatulence and fatty food intolerance. She denies fever, jaundice, or dark urine during any episode. She has never had a sustained fever or prolonged pain episode.

Vitals: T 36.9°C, HR 82, BP 128/80 - all normal

Physical exam: Mild RUQ tenderness on deep palpation. No guarding. Murphy's sign negative. No jaundice, no palpable gallbladder.

Labs (done during a pain-free interval):

WBC: 7,100/mm³ (normal)
LFTs: all normal
CRP: normal

Imaging:

Ultrasound: Multiple small gallstones, thickened and contracted-appearing gallbladder wall, no pericholecystic fluid, no CBD dilation
HIDA scan (if done): may show reduced gallbladder ejection fraction

Test Yourself

What is the diagnosis? How does this differ from acute cholecystitis?
What are the characteristic histological findings of chronic cholecystitis?
What are Rokitansky-Aschoff sinuses and how do they form?
The patient says, "I also have bloating and gas - will surgery fix that?" How do you respond?
What does the contracted, thickened gallbladder wall on US signify?
What is the management? Is there any urgency?
If a HIDA scan shows an ejection fraction of <35%, what does this suggest and does it change management?
What long-term risk must this patient be warned about if surgery is not done?

Answers - Case 3

1. Diagnosis: Chronic cholecystitis (recurrent biliary pain from cholelithiasis). Key distinctions from acute cholecystitis: no fever, no leukocytosis, no elevated CRP, no sustained prolonged pain (>6 hours), and the gallbladder appears contracted/scarred rather than distended and inflamed. The clinical picture is recurrent episodic pain over months/years without systemic signs of infection.

2. Histology of chronic cholecystitis: Marked subepithelial and subserosal fibrosis. The only sign of inflammation (in the absence of superimposed acute attack) is collections of lymphocytes in the gallbladder wall. The mucosa is often intact. - Robbins Pathology, p.633

3. Rokitansky-Aschoff sinuses: These are outpouchings of the mucosal epithelium through the gallbladder wall, forming intramural diverticula. They form as a result of recurrent episodes of increased intraluminal pressure (from obstruction) that force mucosa through weak points in the muscle layer. Bile pigment or stones can become trapped within them. - Robbins Pathology, p.633 & Sleisenger & Fordtran, p.1241

4. Bloating/gas: These symptoms are not caused by gallstones and will likely NOT be relieved by cholecystectomy. Studies show flatulence, bloating, and dyspepsia are found with equal frequency in people with and without gallstones. Patients with only nonspecific GI complaints (without true biliary-type episodic pain) are not candidates for surgery. Only true biliary pain is an indication for cholecystectomy. - Sleisenger & Fordtran, p.1242

5. Contracted gallbladder wall: Reflects the end result of recurrent inflammation and healing - the repeated cycles of injury and repair lead to progressive fibrosis and scarring, causing the gallbladder to shrink and lose its normal distensibility. A thickened contracted gallbladder filled with stones is typical of longstanding chronic cholecystitis.

6. Management: Elective laparoscopic cholecystectomy when the patient has true biliary-type recurrent pain. No urgency unless there is an acute superimposed attack. Surgery should be planned at the patient's convenience.

7. Low ejection fraction on HIDA: An ejection fraction <35% (some use <40% as threshold) suggests gallbladder dysmotility/biliary dyskinesia - a component of acalculous biliary pain or functional gallbladder disorder. This supports the diagnosis even in the absence of stones and can be used to justify cholecystectomy in acalculous cases. In this patient who already has stones, it confirms biliary origin of symptoms.

8. Long-term risk: Gallbladder carcinoma. Cholelithiasis is an important risk factor for gallbladder cancer. The risk is proportional to the duration of gallstone disease and the degree of chronic inflammatory changes. This is one reason elective cholecystectomy is recommended even in minimally symptomatic patients with confirmed stones. - Robbins Pathology

Quick Comparison Table

Feature	Cholelithiasis (Biliary Pain)	Acute Cholecystitis	Chronic Cholecystitis
Pain duration	30 min - 6 hours, self-limited	>6 hours, does NOT resolve	Recurrent episodes, <6 hrs each
Fever	None	Present (38-39°C)	None
WBC	Normal	Elevated (>12,000)	Normal
Murphy's sign	Negative (between attacks)	Positive	Usually negative
CRP	Normal	Elevated	Normal
US gallbladder	Stones, normal wall	Wall thickening >4 mm, pericholecystic fluid	Contracted, fibrosed, stones
Treatment	Elective cholecystectomy	Early cholecystectomy (within 3 days)	Elective cholecystectomy

Cases based on Robbins & Kumar Basic Pathology and Sleisenger & Fordtran's Gastrointestinal and Liver Disease.

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