Cholecystitis Workup

Author: Alan A Bloom, MD; Chief Editor: Julian Katz, MD more...

Updated: Jun 30, 2011

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Approach Considerations
Laboratory Tests
Radiography
Ultrasonography
CT and MRI
Hepatobiliary Scintigraphy
Endoscopic Retrograde Cholangiopancreatography
Histologic Findings
Show All

Approach Considerations

The workup for cholecystitis may include laboratory tests (though these are not always reliable), radiography, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), hepatobiliary scintigraphy (HBS), and endoscopy.

Laboratory Tests

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 undergo pregnancy testing.

A retrospective study by Singer, aimed at determining 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, found that of 40 patients with pathologically confirmed acute cholecystitis, 36 (90%) did not have fever at the time of presentation and 16 (40%) did not have leukocytosis.^[14]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.

Imaging recommendations

The 2010 American College of Radiology (ACR) Appropriateness Criteria offer the following imaging recommendations^[15]:

Sonography is the preferred initial imaging test for the diagnosis of acute cholecystitis, and scintigraphy is the preferred alternative.
CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute cholecystitis, such as gangrene, gas formation, and perforation.
CT with intravenous contrast is useful in diagnosing acute cholecystitis in patients with nonspecific abdominal pain.
MRI, often with intravenous gadolinium-based contrast medium, is also a possible secondary imaging modality useful in confirming a diagnosis of acute cholecystitis.
MRI without contrast is useful to eliminate radiation exposure in pregnant women for whom sonograms have not indicated a clear diagnosis.
Contrast agents should not be used in patients on dialysis unless absolutely necessary.

Radiography

Gallstones may be visualized on noncontrast radiography 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 increased mortality and occurs most commonly in males with diabetes and with acalculous cholecystitis.

Go to Emphysematous Cholecystitis for more complete information on this topic.

A diffusely calcified gallbladder (ie, porcelainized) most commonly is associated with carcinoma, although 2 studies have found no association between partial calcification of the gallbladder and carcinoma.^{[16, 17]}

Other findings may include renal calculi, intestinal obstruction, or pneumonia.

Go to Imaging in Acute Cholecystitis and Imaging in Acalculous Cholecystitis for more complete information on these topics.

Ultrasonography

Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific. It provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Studies indicate that emergency clinicians require minimal training in order to use right upper quadrant ultrasonography in their practice.^{[18, 19, 20, 21, 22, 23]}

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.

Go to Imaging in Acute Cholecystitis and Imaging in Acalculous Cholecystitis for more complete information on these topics.

CT and MRI

The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%.^[24]Spiral CT 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.

Go to Imaging in Acute Cholecystitis and Imaging in Acalculous Cholecystitis for more complete information on these topics.

Hepatobiliary Scintigraphy

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%. (See the following 2 images.)

Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.

Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.

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.

Go to Imaging in Acute Cholecystitis and Imaging in Acalculous Cholecystitis for more complete information on these topics.

Endoscopic Retrograde Cholangiopancreatography

ERCP may be useful for visualizing the anatomy in patients at high risk for gallstones if signs of common bile duct obstruction are present. A study performed by Sahai et al found that ERCP was preferred over endoscopic ultrasonography and intraoperative cholangiography for patients at high risk for common bile duct stones undergoing laparoscopic cholecystectomy.^[25]

Disadvantages of ERCP include the need for a skilled operator, high cost, and complications such as pancreatitis, which occurs in 3-5% of cases.

Go to Imaging in Acute Cholecystitis and Imaging in Acalculous Cholecystitis for more complete information on these topics.

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.

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Alan A Bloom, MD Associate Clinical Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Gastroenterology, Veterans Affairs Hospital, Bronx

Alan A Bloom, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, New York Academy of Medicine, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Zahir Amin, MD, MBBS, MRCP, FRCR Consulting Staff, Department of Imaging, University College Hospital, UK

Zahir Amin, MD, MBBS, MRCP, FRCR is a member of the following medical societies: British Institute of Radiology, British Medical Association, and Royal College of Radiologists

Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

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.

Burt Cagir, MD, FACS Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Hemalatha Chandramohan, MBBS Registrar, General Practice, West Yorkshire, UK

Hemalatha Chandramohan, MBBS is a member of the following medical societies: Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Jack A Di Palma, MD Director, Division of Gastroenterology, Professor, Department of Internal Medicine, University of South Alabama College of Medicine

Jack A Di Palma, MD is a member of the following medical societies: American College of Gastroenterology and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Arnold C Friedman, MD, FACR Professor, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital

Arnold C Friedman, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America

Disclosure: Nothing to disclose.

Spencer B Gay, MD Professor of Radiology, Department of Radiology and Medical Imaging, University of Virginia School of Medicine

Disclosure: Nothing to disclose.

Don Gladden, DO Staff Physician, Department of Emergency Medicine, Seton Medical Center Williamson

Don Gladden, DO is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

John L Haddad, MD Clinical Associate Professor, Department of Radiology, Weill Medical College of Cornell University; Director of Body MRI, Department of Radiology, Methodist Hospital in Houston

John L Haddad, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America

Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Ravi Devidas Kadasne, MBBS, MD Specialist in Radiology, Emirates International Hospital, UAE

Disclosure: Nothing to disclose.

John Karani, MBBS, FRCR Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King's College Hospital, UK

John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, British Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, European Society of Gastrointestinal and Abdominal Radiology, European Society of Radiology, Radiological Society of North America, and Royal College of Radiologists

Disclosure: Nothing to disclose.

Samuel M Keim, MD Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Lalam Radhesh Krishna, MBBS Specialist Registrar, Department of Radiology, North Manchester General Hospital, UK

Disclosure: Nothing to disclose.

J David Lane, MD, RT Chief, CMH Vascular and Interventional Radiology, Wisconsin Radiology Specialists, SC; Former Section Chief, Assistant Professor, Vascular and Interventional Radiology, Walter Reed Army Medical Center, Uniformed Services University of the Health Sciences

J David Lane, MD, RT is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

Nick Lomis, MD QI Coordinator, Diagnostic Radiology Service, Assistant Chief, Interventional Radiology and Diagnostic Radiology, Walter Reed Army Medical Center

Nick Lomis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

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.

H Leon Pachter, MD, FACS Chair, George David Stewart Professor, Department of Surgery, New York University Medical Center

H Leon Pachter, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Surgical Association, American Trauma Society, New York Academy of Sciences, Society for Surgery of the Alimentary Tract, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Manish Parikh, MD Assistant Professor of Surgery, Department of Surgery, New York University School of Medicine; Attending Surgeon, Director Laparoscopic and Bariatric Surgery, Bellevue Hospital

Manish Parikh, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR Consulting Interventional Neuroradiologist, Department of Neuroradiology, Leeds General Infirmary, UK

Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR is a member of the following medical societies: British Society of Neuroradiologists and Royal College of Radiologists

Disclosure: Nothing to disclose.

Tushar Patel, MB, ChB Professor of Medicine, Ohio State University Medical Center

Tushar Patel, MB, ChB is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

Marco G Patti, MD Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Disclosure: Nothing to disclose.

Prospere Remy, MD Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center

Prospere Remy, MD is a member of the following medical societies: American College of Physicians and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Rahul Sharma, MD, MBA, FACEP Assistant Professor, Weill Medical College of Cornell University; Assistant Director for Operations, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Peter A D Steel, MA, MBBS Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals

Peter A D Steel, MA, MBBS is a member of the following medical societies: American College of Emergency Physicians, British Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Alan BR Thomson, MD Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Jeffery Wolff, DO Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center; Staff Gastroenterologist, Landstuhl Regional 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.

Specialty Editor Board

Anil Minocha, MD, FACP, FACG 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; Clinical Professor, University of Mississippi School of Pharmacy

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Walter E Pofahl, MD, Amber A Guth, MD, FACS, Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, and David Sherlock, MBBS, FRCS, to the development and writing of the source articles.

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Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.

Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.

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