What are the diagnostic criteria for acute cholecystitis (inflammation of the gallbladder)?

From the Guidelines

Acute Cholecystitis Diagnostic Criteria The diagnostic criteria for acute cholecystitis (inflammation of the gallbladder) involve a combination of clinical presentation, laboratory findings, and imaging studies, as there is no single investigation with sufficient diagnostic power to establish or exclude acute cholecystitis 1.

Clinical Presentation

• Right upper quadrant abdominal pain
• Fever
• Vomiting or food intolerance
• Murphy’s sign, which is a positive likelihood ratio of 2.8 1

Laboratory Findings

• Elevated white blood cell count
• Elevated C-reactive protein
• Elevated liver enzymes, such as alanine transaminase and aspartate transaminase

Imaging Studies

• Abdominal ultrasound is the preferred initial imaging technique, especially in elderly patients, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1
• Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) may also be used to show gallbladder inflammation, thickening of the gallbladder wall, pericholecystic fluid, or gallstones
• HIDA scan has the highest sensitivity and specificity for acute cholecystitis, but its use is limited by scarce availability, long execution time, and exposure to ionizing radiation 1 It is essential to combine clinical, laboratory, and imaging investigations for an accurate diagnosis, although the best combination is not yet known 1.

From the Research

Diagnostic Criteria for Acute Cholecystitis

The diagnostic criteria for acute cholecystitis include:

• Local signs of inflammation, such as Murphy's sign, or a mass, pain or tenderness in the right upper quadrant 2
• Systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level 2
• Confirmation by diagnostic imaging, such as ultrasonography or hepatobiliary scintigraphy 2, 3

Clinical Presentation

The typical presentation of acute cholecystitis consists of:

• Acute right upper quadrant pain 3
• Fever 3
• Nausea 3
• Right upper quadrant tenderness 4

Diagnostic Tests

Diagnostic tests used to confirm acute cholecystitis include:

• Ultrasonography, which has a sensitivity of approximately 81% and a specificity of approximately 83% 3
• Hepatobiliary scintigraphy, which is the gold standard diagnostic test when an ultrasound result does not provide a definitive diagnosis 3

Severity Assessment

The severity of acute cholecystitis is classified into three grades:

• Grade I (mild acute cholecystitis): no organ dysfunction and limited disease in the gallbladder 2
• Grade II (moderate acute cholecystitis): no organ dysfunction but extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy 2
• Grade III (severe acute cholecystitis): acute cholecystitis with organ dysfunction 2

Limitations of Diagnostic Criteria

The Tokyo Guidelines (TG13) diagnostic criteria have been found to lack sensitivity, missing more than half of the patients with acute cholecystitis, as many patients lack clinical signs such as fever and leukocytosis 5