Recommendations

Key Recommendations

Early diagnosis is essential for prompt therapeutic decisions and prevention of complications. Diagnosis is based on the signs and symptoms of inflammation in the presence of peritonitis localized to the right upper quadrant (RUQ) of the abdomen.[7]​ However, no clinical or laboratory finding has a high or low enough likelihood ratio to predict the presence or absence of the condition.[31]

History

Patients typically complain of nausea and pain that lasts >3-6 hours, which is unremitting and may be associated with fever. The pain is severe and steady.[13][32] The duration of pain can be shorter if the gallstone returns into the gallbladder lumen or passes into the duodenum.

Physical exam

Physical exam may reveal RUQ tenderness or a palpable mass. A positive Murphy sign (the examiner's hand rests along the costal margin and deep inspiration causes pain) has a specificity of 79% to 96% for acute cholecystitis.[33] Persistent pain, fever, chills, and more severe localized or generalized tenderness may indicate complicated disease (e.g., abscess formation or gallbladder perforation).

Acalculous cholecystitis is more difficult to diagnose clinically, as it often occurs in critically ill patients who may not be able to express pain. Patients receiving total parenteral nutrition are at increased risk. Fever, jaundice, vomiting, abdominal tenderness, leukocytosis, and hyperbilirubinemia should lead to a high index of clinical suspicion. Typically, acalculous cholecystitis is a diagnosis of exclusion.

Blood tests

Complete blood count and C-reactive protein should be assessed to look for evidence of an inflammatory process.[7]​​[34][35]​ Liver function tests may show elevated bilirubin, alkaline phosphatase, and gamma glutamyl transferase, though they should not be the only method to identify common bile duct stones.[36]

Imaging

In nonpregnant adults with suspected acute cholecystitis, abdominal ultrasound should be the initial diagnostic imaging modality. If this is equivocal and clinical suspicion persists, an abdominal computed tomography (CT) scan can be considered.[37][38]​​​ RUQ ultrasound should be the first test ordered and can be performed at the patient's bedside.[36]​ Detection of gallstones alone does not definitively diagnose the condition. To make an accurate diagnosis the findings of stones and a sonographic Murphy sign are required. About 92% of patients with a positive sonographic Murphy sign in the presence of gallstones have the condition.[39]​​ [Figure caption and citation for the preceding image starts]: Ultrasound of acute cholecystitis and presence of gallstonesFrom the collection of Dr Charles Bellows; used with permission [Citation ends].Ultrasound of acute cholecystitis and presence of gallstones

Ultrasound allows for evaluation of all the abdominal structures. It provides anatomic information about gallbladder size, stone size, gallbladder wall, and bile duct size.

Scintigraphy with hepatobiliary iminodiacetic acid (HIDA) scan can be considered if ultrasound results and CT results are equivocal, but it is rarely rapidly available in an acute situation.[40] However, HIDA scan has the highest sensitivity and specificity for the diagnosis of acute calculus cholecystitis (ACC) as compared with other imaging modalities.[36][37][38]​​​

Abdominal CT scan is inferior to ultrasound and magnetic resonance imaging (MRI) in assessing acute biliary disease, but it is useful when obesity or gaseous distension limits ultrasound interpretation. It is also indicated for evaluation of suspected complications (e.g., abscess) and concurrent intra-abdominal conditions. Abdominal MRI is appropriate for pregnant patients with abdominal pain and is recommended alongside abdominal ultrasound.[36][37][38][41]

Plain radiographs may detect a radiopaque gallstone in 15% of cases and provide information about bowel gas pattern or free air, but offer no incremental information if ultrasound or CT is performed.[42]

Venepuncture and phlebotomy: animated demonstration
Venepuncture and phlebotomy: animated demonstration

How to take a venous blood sample from the antecubital fossa using a vacuum needle.

Use of this content is subject to our disclaimer