From the Guidelines
The diagnosis of cholecystitis should be based on a combination of clinical presentation, laboratory tests, and imaging studies, with ultrasound being the first-line imaging test due to its high sensitivity and specificity 1.
Clinical Presentation and Laboratory Tests
The clinical presentation of cholecystitis typically includes fever, right upper quadrant pain or tenderness, vomiting or food intolerance, and Murphy’s sign 1. Laboratory tests such as elevated C-reactive protein, elevated white blood cell count, and liver function tests may also support the diagnosis, but are not specific to cholecystitis 1.
- Key laboratory findings include:
- Leukocytosis with white blood cell counts between 12,000-15,000/mm³
- Elevated C-reactive protein and erythrocyte sedimentation rate
- Mild elevations in bilirubin, alkaline phosphatase, AST, and ALT
Imaging Studies
Imaging studies are essential for confirmation of the diagnosis, with ultrasound being the preferred initial imaging technique due to its widespread availability, lack of invasiveness, and reduced costs 1.
- Ultrasound findings that support the diagnosis of cholecystitis include:
- Gallstones
- Gallbladder wall thickening >3mm
- Pericholecystic fluid
- Sonographic Murphy's sign
- Other imaging studies such as HIDA scan and CT scan may be useful in certain cases, but are not the first-line tests 1.
Diagnostic Criteria
The Tokyo Guidelines (TG) criteria for the diagnosis of cholecystitis include clinical signs, laboratory tests, and imaging features 1. However, the accuracy of the TG13 criteria has been reported to be low at 60.3% 1.
- The use of new ultrasonography criteria such as point shear-wave elastography (pSWE) and superb microvascular imaging (SMI) may improve the diagnostic accuracy of ultrasound, but require further study and expertise 1.
Recommendation
Based on the current evidence, a combination of clinical presentation, laboratory tests, and ultrasound imaging is recommended for the diagnosis of cholecystitis 1.
From the Research
Lab Diagnosis of Cholecystitis
- The diagnosis of cholecystitis can be supported by laboratory tests, including liver function tests such as serum bilirubin, aminotransferases, and alkaline phosphatase levels 2.
- Elevated levels of these tests can indicate the presence of common duct stones, with alkaline phosphatase showing the best predictive values 2.
- A study found that the frequency of common duct stones increased with higher degrees of elevation in alkaline phosphatase levels, but not in bilirubin or aminotransferases 2.
- Laboratory tests can also include a complete blood count, with an elevated white blood cell count being a common finding in acute cholecystitis 3.
Imaging Studies
- Imaging studies such as ultrasonography, computed tomography, and magnetic resonance imaging can be used to diagnose cholecystitis and identify complications 3.
- Cholescintigraphy is recommended in patients with equivocal findings on other imaging modalities, as it has the highest diagnostic accuracy in the diagnosis of acute cholecystitis 3.
Other Diagnostic Methods
- There is limited evidence to support the use of other diagnostic methods, such as the response of peritoneal cells to foreign materials, in the diagnosis of cholecystitis 4.
- Other studies have investigated the generation and characterization of temperature-sensitive mutants of the Eastern equine encephalomyelitis virus, but these are not relevant to the diagnosis of cholecystitis 5.