From the Guidelines
Cholecystitis is diagnosed using a combination of clinical, laboratory, and imaging findings, with abdominal ultrasound being the preferred initial imaging technique, as stated in the 2019 WSES guidelines 1. The diagnostic criteria include right upper quadrant pain and tenderness, fever, elevated white blood cell count (leukocytosis), and positive Murphy's sign (pain on inspiration when pressing on the gallbladder). Laboratory tests typically show elevated inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate, along with possible elevations in liver enzymes and bilirubin. Imaging studies are crucial for confirmation, with ultrasound being the first-line modality showing gallbladder wall thickening (>3mm), pericholecystic fluid, and often gallstones. The sonographic Murphy's sign (pain when the ultrasound probe presses on the gallbladder) is highly specific. In cases where ultrasound is inconclusive, a hepatobiliary iminodiacetic acid (HIDA) scan showing non-filling of the gallbladder is diagnostic with over 90% sensitivity, as mentioned in the 2019 WSES guidelines 1. CT scans may be used when complications are suspected, while MRI provides detailed biliary tract imaging. Some key points to consider in the diagnosis of cholecystitis include:
- Combination of symptoms, signs, and laboratory tests results may have better diagnostic accuracy in confirming the diagnosis of acute cholecystitis, as stated in the 2019 WSES guidelines 1.
- Abdominal ultrasound is the preferred initial imaging technique for patients who are clinically suspected of having acute cholecystitis, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones, as mentioned in the 2019 WSES guidelines 1.
- The diagnostic accuracy of CT and MRI might be comparable to that of abdominal ultrasound, but no sufficient data are provided to support this hypothesis, as stated in the 2019 WSES guidelines 1.
- HIDA scan has the highest sensitivity and specificity for acute cholecystitis than other imaging modalities, although its scarce availability, long time of execution, and exposure to ionizing radiations limit its use, as mentioned in the 2019 WSES guidelines 1. The 2020 WSES guidelines 1 and the 2019 WSES guidelines 1 provide the most recent and highest quality evidence for the diagnosis and treatment of acute calculus cholecystitis.
From the Research
Diagnostic Criteria for Cholecystitis
The diagnostic criteria for cholecystitis, as proposed by the Tokyo Guidelines 2, include:
- One of the local signs of inflammation, such as:
- Murphy's sign
- A mass, pain, or tenderness in the right upper quadrant
- One of the systemic signs of inflammation, such as:
- Fever
- Elevated white blood cell count
- Elevated C-reactive protein level
- Confirmation by diagnostic imaging, such as ultrasonography or hepatobiliary scintigraphy
Classification of Acute Cholecystitis
The severity of acute cholecystitis is classified into three grades:
- Grade I (mild): acute cholecystitis with no organ dysfunction and limited disease in the gallbladder
- Grade II (moderate): acute cholecystitis with no organ dysfunction but extensive disease in the gallbladder
- Grade III (severe): acute cholecystitis with organ dysfunction
Diagnostic Challenges
Atypical presentations of acute cholecystitis can make diagnosis challenging 3. In such cases, a thorough work-up, including laboratory tests and imaging studies, is necessary to confirm the diagnosis.
Role of Imaging Studies
Imaging studies, such as ultrasonography, computed tomography, and hepatobiliary scintigraphy, play a crucial role in diagnosing acute cholecystitis 4, 5, 6. These studies can help confirm the presence of gallstones, inflammation, and other signs of cholecystitis.
Clinical Presentation
The typical presentation of acute cholecystitis includes acute right upper quadrant pain, fever, and nausea 6. However, atypical presentations can occur, and a high index of suspicion is necessary to make an accurate diagnosis.