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A 71-year-old man presented to the ED with right upper quadrant pain of two day’s duration.

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The pain began as a dull ache in the midepigastrium and then moved to the right upper quadrant and right flank. He vomited several times and was unable to eat. The emesis was a watery brown material. He had a small bowel movement earlier that day.

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He had a history of diabetes and hypertension and was taking glyburide and lisinopril.

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He had not had prior abdominal surgery.

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On examination, he was overweight and in mild distress due to abdominal discomfort. His blood pressure was 148/100 mm Hg, pulse 110 beats/min, respiratory rate 24 breaths/min, temperature 100.4°C (rectal).

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He was alert and oriented. His oral mucosa was dry and sclera was anicteric. His lungs were clear and his heart was rapid and regular without a murmur.

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Abdominal examination revealed diminished bowel sounds, moderate tenderness in the right upper quadrant, and a Murphy’s sign. There was no tenderness on rectal examination and stool was guiac negative.

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An intravenous line was started and blood specimens were obtained. Intravenous fluids, insulin, and ampicillin/sulbactam were administered.

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Blood test results (units for electrolytes, mEq/L and chemistry values, mg/dL, except where noted):

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  • WBC 19,700/mm3, hematocrit 49%, platelets 246,000/mm3.
  • Na+ 132, K+ 4.1, Cl+ 101, CO2+ 22, BUN 24, creatinine 1.4, glucose 406.
  • ALT 100 U/L (normal: 7–37), AST 65 U/L, alkaline phosphatase 61 U/L (normal: 39–117), total bilirubin 1.6 (normal: 0.2–1.2), lipase 110 U/L (normal).

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A bedside sonogram was performed and the gallbladder could not be confidently identified. The patient was sent to the radiology department for another abdominal ultrasound study. Selected ultrasound images, including the right upper quadrant, are shown in Figure 1.

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  • What is this patient’s likely diagnosis?

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Hint: Under what circumstances would cholecystitis be difficult to diagnose by ultrasound?

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(What tissue characteristics are disadvantageous for sonographic visualization?)

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The correct diagnosis can be confirmed by another simple imaging test.

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