From the Guidelines
Cholecystitis is characterized by right upper quadrant abdominal pain, fever, nausea, vomiting, and anorexia, with laboratory findings including leukocytosis, elevated C-reactive protein, and mildly elevated liver enzymes, as supported by the most recent evidence from 2020 1.
Clinical Findings
The clinical presentation of cholecystitis typically includes:
- Right upper quadrant abdominal pain that may radiate to the right shoulder or back
- Fever
- Nausea
- Vomiting
- Anorexia
- Murphy's sign (pain with inspiration during palpation of the right upper quadrant)
- Abdominal tenderness
- Guarding
- Occasionally, a palpable gallbladder
Laboratory Findings
Laboratory findings in cholecystitis include:
- Leukocytosis with white blood cell counts often exceeding 10,000/mm³
- Elevated C-reactive protein
- Mildly elevated liver enzymes (particularly alkaline phosphatase and gamma-glutamyl transferase)
- Bilirubin may be normal or slightly elevated
- In more severe cases, patients may show signs of systemic inflammation with elevated heart rate and decreased blood pressure
Diagnosis
The diagnosis of cholecystitis is based on a combination of clinical findings, laboratory tests, and imaging studies, with ultrasound being a crucial diagnostic tool, as recommended by the 2020 World Society of Emergency Surgery guidelines 1. The Tokyo Guidelines (TG13) criteria for the diagnosis of cholecystitis include clinical signs, laboratory tests, and imaging features, but have been found to have low accuracy 1.
Imaging Studies
Imaging studies, such as ultrasound, are essential for diagnosing cholecystitis, with findings including:
- Gallstones
- Gallbladder wall thickening (>4mm)
- Pericholecystic fluid
- Sonographic Murphy's sign
These clinical and laboratory findings reflect the underlying pathophysiology of cholecystitis, which typically involves obstruction of the cystic duct by gallstones, leading to gallbladder distension, inflammation, and potential bacterial infection of the trapped bile, as described in the 2019 ACR Appropriateness Criteria 1.
From the Research
Clinical Findings
- Severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphy's sign are the classical clinical manifestations of acute cholecystitis 2
- Older patients with a high white cell count are more likely to have severe gallbladder complications 3
- Patients with perforated cholecystitis tend to have higher levels of white blood cells, neutrophil-lymphocyte ratio, C-reactive protein, and C-reactive protein/albumin ratio 4
Laboratory Findings
- Elevated serum bilirubin, aminotransferases, and alkaline phosphatase levels are commonly observed in patients with acute cholecystitis 5
- White blood cell count, C-reactive protein, and C-reactive protein/albumin ratio may be useful biomarkers in predicting perforated cholecystitis cases 4
- Abnormal liver function tests, such as elevated AST, ALT, and ALP, are often seen in patients with acute cholecystitis 5, 4, 2
Imaging Findings
- Ultrasonography is typically the initial diagnostic examination in patients with suspected acute cholecystitis 2, 6
- Computed tomography and magnetic resonance imaging may be helpful in identifying complications of acute cholecystitis 2, 6
- 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 2, 6