What is the appropriate imaging for a 62-year-old female with two weeks of right upper quadrant (RUQ) pain and a positive Murphy's sign, indicating possible cholecystitis (inflammation of the gallbladder)?

From the Guidelines

The appropriate initial imaging for this 62-year-old female with right upper quadrant pain and positive Murphy sign is an abdominal ultrasound. This non-invasive test should be performed promptly as it is the first-line imaging modality for suspected gallbladder disease, particularly cholecystitis, as recommended by the most recent guidelines 1. The ultrasound can visualize gallstones, gallbladder wall thickening, pericholecystic fluid, and other signs of inflammation.

Key Considerations

• The patient's presentation with localized right upper quadrant pain and positive Murphy sign strongly suggests gallbladder pathology, even in the absence of associated symptoms like nausea or vomiting.
• Ultrasound is preferred as the initial test due to its high sensitivity for gallstones, lack of radiation exposure, wide availability, and cost-effectiveness compared to other imaging modalities like CT or MRI, as supported by recent studies 1.
• If the ultrasound is inconclusive but clinical suspicion remains high, a hepatobiliary iminodiacetic acid (HIDA) scan would be the appropriate next step to evaluate gallbladder function and confirm or rule out cholecystitis, as suggested by recent guidelines 1.

Imaging Modalities

• Ultrasound is the initial imaging modality of choice for suspected acute cholecystitis, with a sensitivity of 88% and specificity of 80% 1.
• CT or MRI may be considered for subsequent imaging if complications of acute cholecystitis are suspected, such as biloma, intraabdominal abscess, or bile duct injury, as recommended by recent guidelines 1.
• HIDA scan is a useful adjunct for evaluating gallbladder function and confirming or ruling out cholecystitis, especially if ultrasound is inconclusive, as suggested by recent studies 1.

From the Research

Imaging Modalities for Cholecystitis

The appropriate imaging for a 62-year-old female with two weeks of right upper quadrant (RUQ) pain and a positive Murphy's sign, indicating possible cholecystitis, includes:

• Ultrasound as the initial imaging modality of choice, due to its ease of accessibility, low cost, lack of ionizing radiation, and excellent spatial resolution 2, 3, 4, 5
• Computed Tomography (CT) as a secondary imaging modality, particularly useful in situations where ultrasound findings are equivocal or to assess suspected complications of acute cholecystitis 3, 4
• Hepato-imino diacetic acid (HIDA) scan, which can be employed to support the diagnosis of acute cholecystitis, especially when combined with abdominal ultrasound, as it has a high sensitivity for diagnosing acute cholecystitis 6
• Magnetic Resonance Imaging (MRI) or Magnetic Resonance Cholangiopancreatography (MRCP), typically reserved for problem-solving and evaluating patients who present with cholestatic presentation 4

Ultrasound Findings

Ultrasound findings that are associated with a diagnosis of acute cholecystitis include:

• Sonographic Murphy's sign, which has a high positive predictive value for acute cholecystitis when combined with gallstones and acute pain 5
• Gallbladder distension and gallbladder wall thickening, which are common findings in acute cholecystitis, but can also be seen in other conditions 6, 5
• Gallstones, which are a common cause of acute cholecystitis and can be detected by ultrasound 3, 6, 5

Diagnostic Approach

The diagnostic approach for suspected acute cholecystitis should include:

• Clinical evaluation, including physical examination and medical history
• Ultrasound as the initial imaging modality, performed with right subcostal oblique, longitudinal, and intercostal scans
• CT or HIDA scan as secondary imaging modalities, depending on the clinical presentation and ultrasound findings
• MRI or MRCP for problem-solving and evaluating patients with cholestatic presentation 4, 5