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Three Part Question

In [patients with right upper quadrant pain] does [clinical examination] accurately exclude [diagnosis of cholecystitis]?

Clinical Scenario

A patient presents to the accident and emergency department with acute onset of right upper quadrant pain. They have some associated clinical findings such as a positive murphy’s sign and you wonder if this is enough to evidence to make a diagnosis of cholecystitis.

Search Strategy

MEDLINE (1950-2008) and EMBASE database searches
[(exp cholecystitis OR cholecystitis.mp OR exp cholangitis OR cholangitis.mp OR exp biliary tract diseases OR exp gall bladder diseases OR exp gall stones OR gall stones.mp OR right upper quadrant pain .mp OR RUQ pain.mp)AND (exp physical examination OR clinical examination.mp or clinical findings.mp)]

Search Outcome

1324 articles. Of which 1 was a systematic review and 1 other was relevant but not included in the review

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

Clinical diagnosis using all the available clinical signs results is accurate at diagnosing cholecystitis. It seems that Murphy’s sign has high specificity, meaning that patients presenting with this sign are likely to have cholecystitis. Right upper quadrant pain may also be a good indicator of cholecystitis. However, at present it seems that no single clinical finding is adequate to diagnose or rule out cholecystitis

Clinical Bottom Line

If Murphy’s sign is positive in the presence of RUQ pain, this is sufficiently specific for a diagnosis of cholecystitis. If no Murphy’s sign is present, the patient may still have cholecystitis

References

1. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA 2003 Jan 1;289(1):80-6.
2. Mills LD, Mills T, Foster B. Association of clinical and laboratory variables with ultrasound findings in right upper quadrant abdominal pain. South Med J. 2005 Feb;98(2):138.