eMedicine Specialties > Gastroenterology > Biliary

Cholecystitis: Differential Diagnoses & Workup

Author: Don Gladden, DO, Staff Physician, Department of Emergency Medicine, Seton Medical Center
Coauthor(s): Alexandre F Migala, DO, Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center; Clinton S Beverly, MD, Clinical Assistant Professor, Department of Surgery, Mercer University School of Medicine; Jeffery Wolff, DO, Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center
Contributor Information and Disclosures

Updated: Aug 4, 2008

Differential Diagnoses

Abdominal Aortic Aneurysm
Gastritis, Acute
Acute Mesenteric Ischemia
Gastroesophageal Reflux Disease
Amebic Hepatic Abscesses
Hepatitis, Viral
Appendicitis
Myocardial Infarction
Biliary Colic
Nephrolithiasis
Biliary Disease
Pancreatitis, Acute
Cholangiocarcinoma
Peptic Ulcer Disease
Cholangitis
Pneumonia, Bacterial
Choledocholithiasis
Pregnancy and Urolithiasis
Cholelithiasis
Pyelonephritis, Acute
Gallbladder Cancer
Renal Disease and Pregnancy
Gallbladder Mucocele
Renal Vein Thrombosis
Gallbladder Tumors
Gastric Ulcers

Workup

Laboratory Studies

  • A retrospective study by Singer attempted to determine a set of clinical and laboratory parameters that could be used to predict the outcome of hepatobiliary scintigraphy (HBS) in all patients with suspected acute cholecystitis.2
    • The results of the study showed that, in 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the patients, respectively.
    • The study also found that no combination of laboratory or clinical values was useful in identifying patients at high risk for a positive HBS finding.
  • Although laboratory criteria are not reliable in identifying all patients with cholecystitis, the following findings may be useful in arriving at the diagnosis:
    • Leukocytosis with a left shift may be observed in cholecystitis.
    • Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction.
    • Bilirubin and alkaline phosphatase assays are used to evaluate evidence of common duct obstruction.
    • Amylase/lipase assays are used to evaluate the presence of pancreatitis. Amylase may also be elevated mildly in cholecystitis.
    • An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.
    • Urinalysis is used to rule out pyelonephritis and renal calculi.
    • All females of childbearing age should have pregnancy testing.

Imaging Studies

  • Radiography (without contrast)
    • Gallstones may be visualized in 10-15% of cases. This finding only indicates cholelithiasis, with or without active cholecystitis.
    • Subdiaphragmatic free air cannot originate in the biliary tract, and, if present, it indicates another disease process.
    • Gas limited to the gallbladder wall or lumen represents emphysematous cholecystitis, usually because of gas-forming bacteria, such as Escherichia coli and clostridial and anaerobic streptococci species. Emphysematous cholecystitis is associated with an increased mortality rate and occurs most commonly in males with diabetes and with acalculous cholecystitis.
    • A diffusely calcified gallbladder (ie, porcelainized) most commonly is associated with carcinoma, although one retrospective study by Towfigh found no association between partial calcification of the gallbladder and carcinoma.3
    • Other findings may include renal calculi, intestinal obstruction, or pneumonia.
  • Ultrasonography
    • Ultrasonography provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific. Studies indicate that emergency clinicians require minimal training in order to use right upper quadrant ultrasonography in their practice.
    • Ultrasonographic findings that are suggestive of acute cholecystitis include the following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm, and sonographic Murphy sign. The presence of gallstones also helps to confirm the diagnosis.
    • Ultrasonography is performed best following a fast of at least 8 hours because gallstones are visualized best in a distended bile-filled gallbladder.
  • Hepatobiliary scintigraphy (hepatoiminodiacetic acid [HIDA]/diisopropyl iminodiacetic acid [DISIDA])
    • HBS has been found to be up to 95% accurate in diagnosing acute cholecystitis. The reported sensitivities and specificities of biliary scintigraphy are in the range of 90-100% and 85-95%.
    • In a typical study, the gallbladder, common bile duct, and small bowel fill within 30-45 minutes.
    • If the gallbladder is not visualized, intravenous morphine administration can improve the accuracy of HBS by increasing resistance to flow through the sphincter of Oddi, resulting in filling of the gallbladder if the cystic duct is patent. The addition of morphine also reduces the number of false-positive scan results observed in patients who are critically ill and immobilized with viscous bile.
  • CT scan and MRI
    • The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%. SpiralCT scan and MRI (unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the advantage of being noninvasive, but they have no therapeutic potential and are most appropriate in cases where stones are unlikely.
    • Findings suggestive of cholecystitis include wall thickening (>4 mm), pericholecystic fluid, subserosal edema (in the absence of ascites), intramural gas, and sloughed mucosa.
    • CT scan and MRI are also useful for viewing surrounding structures if the diagnosis is uncertain.

Procedures

  • Endoscopic retrograde cholangiopancreatography
    • ERCP may be useful in patients at high risk for common duct gallstones if signs of common bile duct obstruction are present.
    • A study performed by Sahai et al found that ERCP was preferred over endoscopic ultrasound and intraoperative cholangiography for patients at high risk for common duct stones undergoing laparoscopic cholecystectomy.4
    • ERCP allows visualization of the anatomy and may be therapeutic by removing stones from the common bile duct.
    • Disadvantages include the need for a skilled operator, high cost, and complications such as pancreatitis, which occurs in 3-5% of cases.
  • Endoscopic ultrasound-guided transmural cholecystostomy: Recent studies indicate that this procedure may be safe as initial, interim, or definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy.5

Histologic Findings

Edema and venous congestion are early acute changes. Acute cholecystitis is usually superimposed on a histologic picture of chronic cholecystitis. Specific findings include fibrosis, flattening of the mucosa, and chronic inflammatory cells. Mucosal herniations known as Rokitansky-Aschoff sinuses are related to increased hydrostatic pressure and are present in 56% of cases. Focal necrosis and an influx of neutrophils may also be present. Advanced cases may show gangrene or perforation.

More on Cholecystitis

Overview: Cholecystitis
Differential Diagnoses & Workup: Cholecystitis
Treatment & Medication: Cholecystitis
Follow-up: Cholecystitis
Multimedia: Cholecystitis
References
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References

  1. Cullen JJ, Maes EB, Aggrawal S, et al. Effect of endotoxin on opossum gallbladder motility: a model of acalculous cholecystitis. Ann Surg. Aug 2000;232(2):202-7. [Medline].

  2. Singer AJ, McCracken G, Henry MC, et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):267-72. [Medline].

  3. Towfigh S, McFadden DW, Cortina GR, et al. Porcelain gallbladder is not associated with gallbladder carcinoma. Am Surg. Jan 2001;67(1):7-10. [Medline].

  4. Sahai AV, Mauldin PD, Marsi V, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc. Mar 1999;49(3 Pt 1):334-43. [Medline].

  5. Lee SS, Park do H, Hwang CY, et al. EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study. Gastrointest Endosc. Nov 2007;66(5):1008-12. [Medline].

  6. Siddiqui T, MacDonald A, Chong PS, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg. Jan 2008;195(1):40-7. [Medline].

  7. Bingener J, Schwesinger WH, Chopra S, et al. Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?. Am J Surg. Dec 2004;188(6):703-7.

  8. Chiu HH, Chen CM, Mo LR. Emphysematous cholecystitis. Am J Surg. Sep 2004;188(3):325-6. [Medline].

  9. Cox MR, Wilson TG, Luck AJ, et al. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg. Nov 1993;218(5):630-4. [Medline].

  10. Donovan JM. Physical and metabolic factors in gallstone pathogenesis. Gastroenterol Clin North Am. Mar 1999;28(1):75-97. [Medline].

  11. Forbes LE, Bajaj M, McGinn T, et al. Perihepatic abscess formation in diabetes: a complication of silent gallstones. Am J Gastroenterol. Apr 1996;91(4):786-8. [Medline].

  12. Greenwald JA, McMullen HF, Coppa GF, et al. Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis. Ann Surg. Mar 2000;231(3):339-44. [Medline].

  13. Gruber PJ, Silverman RA, Gottesfeld S, et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):273-7. [Medline].

  14. Jang T, Aubin C, Naunheim R. Minimum training for right upper quadrant ultrasonography. Am J Emerg Med. Oct 2004;22(6):439-43. [Medline].

  15. Liolios A, Oropello JM, Benjamin E. Gastrointestinal complications in the intensive care unit. Clin Chest Med. Jun 1999;20(2):329-45, viii. [Medline].

  16. Lo CM, Liu CL, Fan ST, et al. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. Apr 1998;227(4):461-7. [Medline].

  17. McEvoy CF, Suchy FJ. Biliary tract disease in children. Pediatr Clin North Am. Feb 1996;43(1):75-98. [Medline].

  18. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emerg Med Clin North Am. Nov 1996;14(4):719-37. [Medline].

  19. Roe J. Evidence-based emergency medicine. Clinical assessment of acute cholecystitis in adults. Ann Emerg Med. Jul 2006;48(1):101-3. [Medline].

  20. Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in patients with suspected cholecystitis. Am J Emerg Med. Jan 2001;19(1):32-6. [Medline].

  21. Rubens DJ. Hepatobiliary imaging and its pitfalls. Radiol Clin North Am. Mar 2004;42(2):257-78. [Medline].

  22. Shah K, Wolfe RE. Hepatobiliary ultrasound. Emerg Med Clin North Am. Aug 2004;22(3):661-73, viii. [Medline].

  23. Silberfein EJ, Zhou W, Kougias P, et al. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program. Am J Surg. Nov 2007;194(5):672-7. [Medline].

  24. Sitzmann JV, Pitt HA, Steinborn PA, et al. Cholecystokinin prevents parenteral nutrition induced biliary sludge in humans. Surg Gynecol Obstet. Jan 1990;170(1):25-31. [Medline].

  25. Yates MR 3rd, Baron TH. Biliary tract disease in pregnancy. Clin Liver Dis. 1999;3:131-147.

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Further Reading

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Keywords

cholecystitis, cholelithiasis, gallstones, gallbladder stones, gallbladder inflammation, cystic duct obstruction, cystic duct stones, acute cholecystitis, chronic cholecystitis, emphysematous cholecystitis, acalculous cholecystitis, calculous cholecystitis, stones in the cystic duct, obstruction of the cystic duct, biliary pain, acalculous biliary colic, calculous biliary colic, biliary stasis, cholecystectomy, sepsis, long-term total parenteral nutrition, long-term TPN, prolonged fasting, sickle cell disease, Salmonella infections, diabetes mellitus, cytomegalovirus, cryptosporidiosis, microsporidiosis infections, obesity, jaundice, major surgery, severe trauma, severe burns, myocardial infarction

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Contributor Information and Disclosures

Author

Don Gladden, DO, Staff Physician, Department of Emergency Medicine, Seton Medical Center
Don Gladden, DO is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Alexandre F Migala, DO, Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center
Alexandre F Migala, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association, Association of Military Osteopathic Physicians and Surgeons, and Texas Medical Association
Disclosure: Nothing to disclose.

Clinton S Beverly, MD, Clinical Assistant Professor, Department of Surgery, Mercer University School of Medicine
Clinton S Beverly, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Jeffery Wolff, DO, Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center
Jeffery Wolff, DO is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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