From the Guidelines
A gallbladder workup should begin with ultrasound of the right upper quadrant as the initial imaging study of choice. This is due to its high sensitivity for detecting gallstones, gallbladder wall thickening, and biliary dilation, as reported by the American College of Radiology in 2019 1. The ultrasound is very accurate at diagnosing or excluding gallstones with a reported accuracy of 96% for detection of gallstones.
Initial Evaluation
The initial evaluation should include a thorough history and physical examination, followed by laboratory tests including liver function tests (ALT, AST, alkaline phosphatase, bilirubin), complete blood count, and lipase/amylase.
Imaging Studies
- Ultrasound is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, as it is very accurate at diagnosing or excluding gallstones and may differentiate cholelithiasis from gallbladder sludge, polyps, or masses 1.
- If ultrasound is inconclusive but clinical suspicion remains high, a HIDA scan can assess gallbladder function and detect cystic duct obstruction.
- For patients with suspected common bile duct stones, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound may be warranted.
- CT scanning is less sensitive for gallstones but useful for complications like pancreatitis or perforation, and may reveal such complications as gangrene, gas formation, intraluminal hemorrhage, and perforation 1.
Management
Patients with symptomatic gallstones typically require cholecystectomy, while those with asymptomatic gallstones generally need no intervention. The workup aims to distinguish gallbladder disease from other causes of abdominal pain and determine appropriate management based on the specific pathology identified. Laboratory abnormalities suggesting cholestasis (elevated bilirubin, alkaline phosphatase) with right upper quadrant pain strongly indicate biliary pathology.
Additional Considerations
It is essential to note that some patients with complicated cholecystitis may present just like those with noncomplicated disease, and ultrasound remains the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, even in suspected complicated cholecystitis 1.
From the FDA Drug Label
Eighty percent of lithocholic acid formed in the small bowel is excreted in the feces, but the 20% that is absorbed is sulfated at the 3-hydroxyl group in the liver to relatively insoluble lithocholyl conjugates which are excreted into bile and lost in feces. The overall effect of ursodiol is to increase the concentration level at which saturation of cholesterol occurs The various actions of ursodiol combine to change the bile of patients with gallstones from cholesterol-precipitating to cholesterol-solubilizing, thus resulting in bile conducive to cholesterol stone dissolution. Serial ultrasonographic examinations should be obtained to monitor for recurrence of stones, bearing in mind that radiolucency of the stones should be established before another course of Ursodiol is instituted.
Gallbladder Workup
- The drug label does not provide a specific workup for gallbladder disease.
- However, it mentions that serial ultrasonographic examinations should be obtained to monitor for recurrence of stones.
- It also mentions that radiolucency of the stones should be established before another course of Ursodiol is instituted 2.
- Alternative therapies such as watchful waiting and cholecystectomy are discussed in the context of managing gallstones, but a specific workup is not described 2.
From the Research
Gallbladder Workup
The gallbladder is a source of common disease processes with a wide variety of presentations, including acute or chronic cholecystitis, adenomyomatosis, cancer, polyps, and postoperative complications 3.
Imaging Modalities
- Ultrasound is the imaging modality of choice for the initial evaluation of patients who present with right upper quadrant pain 3, 4, 5.
- CT is often used as part of a broader evaluation of patient's abdominal pain if nongallbladder pathologies are also suspected 3.
- MRI/MRCP is typically reserved for problem-solving and evaluating patients who present with cholestatic presentation 3.
Diagnostic Approaches
- Accurate imaging assessment of the gallbladder can be very challenging and fraught with potential pitfalls 3.
- Liver function tests can be used to predict the presence of common duct stones in patients with acute cholecystitis, with elevated serum bilirubin, aminotransferases, and alkaline phosphatase levels observed in a significant proportion of cases 6.
- A holistic approach to ultrasound examination of the gallbladder, including grey scale, Doppler, CEUS, elastography, and 3D, can provide specific information and help establish an accurate non-invasive diagnosis 4.