A 52-year-old woman with a 10-year history of asymptomatic gallstones is found incidentally on ultrasound during evaluation for dyspepsia. Her liver function tests are normal. In contrast, a 48-year-old man presents with acute right upper quadrant pain, fever (38.5°C), and Murphy's sign positive; ultrasound shows gallstones with gallbladder wall thickening and pericholecystic fluid. Which feature BEST discriminates acute cholecystitis from asymptomatic cholelithiasis?

Explanation

## Discriminating Asymptomatic Cholelithiasis from Acute Cholecystitis ### Key Distinction **Key Point:** Asymptomatic cholelithiasis is defined by the presence of gallstones WITHOUT inflammation or symptoms, whereas acute cholecystitis is characterized by acute gallbladder inflammation with clinical and imaging evidence of inflammation. ### Comparison Table | Feature | Asymptomatic Cholelithiasis | Acute Cholecystitis | |---------|---------------------------|---------------------| | **Gallstones** | Present | Present | | **Fever** | Absent | Present (>38°C typical) | | **Murphy's sign** | Negative | Positive | | **WBC count** | Normal | Elevated (>11,000/μL) | | **Imaging: wall thickening** | Absent | Present (>3 mm) | | **Imaging: pericholecystic fluid** | Absent | Present | | **LFTs (bilirubin, ALP)** | Normal | May be normal or mildly elevated | | **Symptoms** | None | Acute RUQ pain, tenderness | ### Clinical Pearl **Clinical Pearl:** The presence of gallstones alone (cholelithiasis) does NOT define cholecystitis. Cholecystitis requires evidence of acute inflammation: clinical signs (fever, Murphy's sign), laboratory markers (leukocytosis), and imaging findings (wall thickening, pericholecystic fluid). Approximately 80% of patients with gallstones remain asymptomatic throughout life. ### High-Yield Fact **High-Yield:** Murphy's sign (inspiratory arrest during deep palpation of the RUQ) is a clinical hallmark of acute cholecystitis and is absent in asymptomatic cholelithiasis. It reflects acute gallbladder inflammation and is more specific than pain alone. ### Why Option 2 is Correct Option 2 captures the **constellation of acute inflammation**: fever, leukocytosis, positive Murphy's sign, AND imaging evidence of gallbladder wall inflammation (thickening, pericholecystic fluid). This combination is pathognomonic for acute cholecystitis and is absent in asymptomatic cholelithiasis. [cite:Sabiston Textbook of Surgery 21e Ch 54]